Take Heart America: A comprehensive, community-wide, systems-based approach to the treatment of cardiac arrest*:

The impact of hospital experience with out-of-hospital cardiac arrest patients on post cardiac arrest care

OBJECTIVE

Patient volume as a surrogate for institutional experience has been associated with quality of care indicators for a variety of illnesses. We evaluated the association between hospital experience with comatose out-of-hospital cardiac arrest (OHCA) patients and important care processes.

METHODS

This was a population-based, retrospective cohort study using data from 37 hospitals in Southern Ontario from 2007 to 2013. We included adults with atraumatic OHCA who were comatose on emergency department arrival and survived at least 6h. We excluded patients with a Do-Not-Resuscitate order or severe bleeding within 6h of hospital arrival. Multi-level logistic regression models estimated the association between average annual hospital volume of OHCA patients and outcomes. The primary outcome was successful targeted temperature management (TTM) and secondary outcomes included TTM initiation, premature withdrawal of life-sustaining therapy, and survival with good neurologic function.

RESULTS

Our analysis included 2723 patients. For every increase of 10 in the average annual volume of eligible patients, the adjusted odds increased by 30% for successful TTM (OR 1.29, 95% CI 1.03-1.62) and by 38% for initiating TTM (OR 1.38, 95% CI 1.11-1.72). No significant association between patient volume and other secondary outcomes was observed.

CONCLUSIONS

Patients arriving at hospitals with more experience treating comatose post cardiac arrest patients are more likely to have TTM initiated and to successfully reach target temperature. Our findings have implications for regional systems of care and knowledge translation efforts aiming to improve quality of care for this patient population.

Sudden Cardiac Death in the Young

Although the occurrence of sudden cardiac death (SCD) in a young person is a rare event, it is traumatic and often widely publicized. In recent years, SCD in this population has been increasingly seen as a public health and safety issue. This review presents current knowledge relevant to the epidemiology of SCD and to strategies for prevention, resuscitation, and identification of those at greatest risk. Areas of active research and controversy include the development of best practices in screening, risk stratification approaches and postmortem evaluation, and identification of modifiable barriers to providing better outcomes after resuscitation of young SCD patients. Institution of a national registry of SCD in the young will provide data that will help to answer these questions.

Strategy analysis of cardiopulmonary resuscitation training in the community

Bystander cardiopulmonary resuscitation (CPR) is a crucial therapy for sudden cardiac arrest. This appreciation produced immense efforts by professional organizations to train laypeople for CPR skills. However, the rate of CPR training is low and varies widely across communities. Several strategies are used in order to improve the rate of CPR training and are performed in some advanced countries. The Chinese CPR training in communities could gain enlightenment from them.

Evaluation of Zoll Medical's ResQCPR System for cardiopulmonary resuscitation

Cardiac arrest remains a leading cause of death, currently affecting more than 250,000 Americans annually. As recommended by the American Heart Association, the current standard of care for patients with an out-of-hospital cardiac arrest (OHCA) includes manual cardiopulmonary resuscitation (S-CPR). Survival with favorable neurological function for all patients following OHCA and treated with S-CPR averages <6%. The ResQCPR System is intended to provide greater circulation to the heart and brain compared with S-CPR, thereby increasing the likelihood of survival. A recent Phase III, multicenter randomized study demonstrated a 50% increase in survival to hospital discharge with favorable neurologic function in subjects with an OHCA of presumed cardiac etiology treated with the ResQCPR System compared with conventional CPR. The ResQCPR System has been recently approved by the FDA as a CPR adjunct to improve the likelihood of survival in adult patients with non-traumatic cardiac arrest.

Usefulness of cardiac arrest centers - extending lifesaving post-resuscitation therapies: the Arizona experience -

The post-cardiac arrest syndrome is a complex, multisystems response to the global ischemia and reperfusion injury that occurs with the onset of cardiac arrest, its treatment (cardiopulmonary resuscitation) and the re-establishment of spontaneous circulation. Regionalization of post-cardiac arrest care, utilizing specified cardiac arrest centers (CACs), has been proposed as the best solution to providing optimal care for those successfully resuscitated after out-of-hospital cardiac arrest. A multidisciplinary team of intensive care specialists, including critical care/pulmonologists, cardiologists (general, interventional, and electrophysiology), neurologists, and physical medicine/rehabilitation experts, is crucial for such centers. Particular attention to the timely initiation of targeted temperature management and early coronary angiography/percutaneous coronary intervention is best provided by such CACs. A State-wide program of CACs was started in Arizona in 2007. This is a voluntary program, whereby medical centers agree to provide all resuscitated cardiac arrest patients brought to their facility with state-of-the-art post-resuscitation care, including targeted temperature management for comatose patients and strong consideration for emergent coronary angiography for all patients with a likely cardiac etiology for their cardiac arrest. Survival improved by more than 50% at facilities that became CACs with a commitment to provide aggressive post-resuscitation care to all such patients. Providing aggressive, post-resuscitation care is the next real opportunity to increase long-term survival for cardiac arrest patients.

Quality of post arrest care does not differ by time of day at a specialized resuscitation center

Previous studies suggest worse outcomes after out-of-hospital cardiac arrest (OHCA) at night. We analyzed whether patients admitted after nontraumatic OHCA to a resuscitation center received the same quality post arrest care at day and night and whether quality of care affected clinical outcomes. We analyzed data of OHCA patients with return of spontaneous circulation admitted to the Vienna general hospital emergency department between January 2006 and May 2013. Data reported include admission time (day defined from 8 AM to 4 PM based on staffing), time to initiation of hypothermia, and door-to-balloon time in patients with ST-elevation myocardial infarction. Survival and cognitive performance at 12 months were assessed. In this retrospective observational study, 1059 patients (74% males, n = 784) with a mean age of 58 ± 16 years were analyzed. The vast majority was treated with induced hypothermia (77% of day vs. 79% of night admissions, P = 0.32) within 1 hour of admission (median time admission to cooling 27 (confidence interval [CI]: 10-60) vs. 23 (CI: 11-59) minutes day vs. night, P = 0.99). In 298 patients with ST-elevation myocardial infarction, median door-to-balloon time did not differ between day and night admissions (82 minutes, CI: 60 to 142 for day vs. 86 minutes, CI: 50 to 135 for night, P = 0.36). At 12 months, survival was recorded in 238 of 490 day and 275 of 569 night admissions (49% vs. 48%, P = 0.94%), and a good neurologic outcome was recorded in 210 of 490 day and 231 of 569 night admissions (43% vs. 41%, P = 0.46). Patients admitted to our department after OHCA were equally likely to receive timely high-quality postresuscitation care irrespective of time of day. Survival and good neurologic outcome at 12 months did not differ between day and night admissions. Our results may support the concept of specialized post arrest care centers.

Current Approaches to Cardiopulmonary Resuscitation

Real progress has been made in improving long-term outcome after out-of-hospital cardiac arrest in the past 10 years. Many communities have doubled their survival-to-hospital-discharge rate during this period. Common features of such successful programs include the following: (1) 911 dispatcher-assisted cardiopulmonary resuscitation (CPR) instruction, (2) bystander chest compression-only CPR program, (3) public access defibrillation, including targeted automated external defibrillator programs, (4) renewed emphasis on minimally interrupted chest compressions by emergency medical services responders, and (5) aggressive postresuscitation care, including targeted temperature management and early coronary angiography and intervention. An important lesson from these successful community efforts is that multiple, simultaneous changes to the local cardiac arrest response system are necessary to improve survival. The next exciting step in this quest appears to be the treatment of refractory cardiac arrest with the combination of mechanical CPR, intra-arrest hypothermia, extracorporeal CPR with mechanical circulatory support devices, and early coronary intervention.

Optimizing neurologically intact survival from sudden cardiac arrest: a call to action

The U.S. national out-of-hospital and in-hospital cardiac arrest survival rates, although improving recently, have remained suboptimal despite the collective efforts of individuals, communities, and professional societies. Only until very recently, and still with inconsistency, has focus been placed specifically on survival with pre-arrest neurologic function. The reality of current approaches to sudden cardiac arrest is that they are often lacking an integrative, multi-disciplinary approach, and without deserved funding and outcome analysis. In this manuscript, a multidisciplinary group of authors propose practice, process, technology, and policy initiatives to improve cardiac arrest survival with a focus on neurologic function.

Defibrillation in rural areas

AIM OF THE STUDY

Automated external defibrillation (AED) and public access defibrillation (PAD) have become cornerstones in the chain of survival in modern cardiopulmonary resuscitation. Most studies of AED and PAD have been performed in urban areas, and evidence is scarce for sparsely populated rural areas. The aim of this review was to review the literature and discuss treatment strategies for out-of-hospital cardiac arrest in rural areas.

METHODS

A Medline search was performed with the keywords automated external defibrillation (617 hits), public access defibrillation (256), and automated external defibrillator public (542). Of these 1415 abstracts and additional articles found by manually searching references, 92 articles were included in this nonsystematic review.

RESULTS

Early defibrillation is crucial for survival with good neurological outcome after cardiac arrest. Rapid defibrillation can be a challenge in sparsely populated and remote areas, where the incidence of cardiac arrest is low and rescuer response times can be long. The few studies performed in rural areas showed that the introduction of AED programs based on a 2-tier emergency medical system, consisting of Basic Life Support and Advanced Life Support teams, resulted in a decrease in collapse-to-defibrillation times and better survival of patients with out-of-hospital cardiac arrest.

CONCLUSIONS

In rural areas, introducing AED programs and a 2-tier emergency medical system may increase survival of out-of-hospital cardiac arrest patients. More studies on AED and PAD in rural areas are required.

SOPs and the right hospitals to improve outcome after cardiac arrest

Approximately 400,000 Europeans are yearly resuscitated from out-of-hospital cardiac arrest (OHCA).(1,2) Despite evolving evidence based guidelines for cardiopulmonary resuscitation (CPR), survival rates after OHCA has not improved much in several places around the world. However, a potential for improved survival is absolutely present, based on the huge spread in worldwide survival; some cities with survival over 20-30% and some cities with just a few percent.(1,2) These survival differences can partly be explained by different definitions of OHCA,(2) but mainly due to the overall quality of the local Chain of Survival (COS)(3); early arrest recognition and call for help, early CPR, early defibrillation and early post resuscitation care. By identifying and thereafter improving weak links in the local COS, survival can indeed increase. This review will focus on the quality of the last link in the COS, the hospital treatment after return of spontaneuous circulation (ROSC), and how good quality post resuscitation care can improve not only survival, but survival with neurologically intact outcome.

Effectiveness of SAPS III to predict hospital mortality for post-cardiac arrest patients

PURPOSE

The mortality for patients admitted to intensive care unit (ICU) after cardiac arrest (CA) remains high despite advances in resuscitation and post-resuscitation care. The Simplified Acute Physiology Score (SAPS) III is the only score that can predict hospital mortality within an hour of admission to ICU. The objective was to evaluate the performance of SAPS III to predict mortality for post-CA patients.

METHODS

This retrospective single-center observational study included all patients admitted to ICU after CA between August 2010 and March 2013. The calibration (standardized mortality ratio [SMR]) and the discrimination of SAPS III (area under the curve [AUC] for receiver operating characteristic [ROC]) were measured. Univariate logistic regression tested the relationship between death and scores for SAPS III, SAPS II, Sequential Organ Failure Assessment (SOFA) Score and Out-of-Hospital Cardiac Arrests (OHCA) score. Independent factors associated with mortality were determined.

RESULTS

One-hundred twenty-four patients including 97 out-of-hospital CA were included. In-hospital mortality was 69%. The SAPS III was unable to predict mortality (SMRSAPS III: 1.26) and was less discriminating than other scores (AUCSAPSIII: 0.62 [0.51, 0.73] vs.

AUCSAPSII

0.75 [0.66, 0.84], AUCSOFA: 0.72 [0.63, 0.81], AUCOHCA: 0.84 [0.77, 0.91]). An early return of spontaneous circulation, early resuscitation care and initial ventricular arrhythmia were associated with a better prognosis.

CONCLUSIONS

The SAPS III did not predict mortality in patients admitted to ICU after CA. The amount of time before specialized CPR, the low-flow interval and the absence of an initial ventricular arrhythmia appeared to be independently associated with mortality and these factors should be used to predict mortality for these patients.

Awakening after cardiac arrest and post resuscitation hypothermia: are we pulling the plug too early?

BACKGROUND

Time to awakening after out-of-hospital cardiac arrest (OHCA) and post-resuscitation therapeutic hypothermia (TH) varies widely. We examined the time interval from when comatose OHCA patients were rewarmed to 37°C to when they showed definitive signs of neurological recovery and tried to identify potential predictors of awakening.

METHODS

With IRB approval, a retrospective case study was performed in OHCA patients who were comatose upon presentation to a community hospital during 2006-2010. They were treated with TH (target of 33°C) for 24h, rewarmed, and discharged alive. Comatose patients were generally treated medically after TH for at least 48h before any decision to withdraw supportive care was made. Pre-hospital TH was not used. Data are expressed as medians and interquartile range.

RESULTS

The 89 patients treated with TH in this analysis were divided into three groups based upon the time between rewarming to 37°C and regaining consciousness. The 69 patients that regained consciousness in ≤48h after rewarming were termed "early-awakeners". Ten patients regained consciousness 48-72h after rewarming and were termed "intermediate-awakeners". Ten patients remained comatose and apneic >72h after rewarming but eventually regained consciousness; they were termed "late-awakeners". The ages for the early, intermediate and late awakeners were 56 [49,65], 62 [48,74], and 58 [55,65] years, respectively. Nearly 67% were male. Following rewarming, the time required to regain consciousness for the early, intermediate and late awakeners was 9 [2,18] (range 0-47), 60.5 [56,64.5] (range 49-71), and 126 [104,151]h (range 73-259), respectively. Within 90 days of hospital admission, favorable neurological function based on a Cerebral Performance Category (CPC) score of 1 or 2 was reported in 67/69 early, 10/10 intermediate, and 8/10 late awakeners.

CONCLUSION

Following OHCA and TH, arbitrary withdrawal of life support <48h after rewarming may prematurely terminate life in many patients with the potential for full neurological recovery. Additional clinical markers that correlate with late awakening are needed to better determine when withdrawal of support is appropriate in OHCA patients who remain comatose >48h after rewarming.

Implementation of the fifth link of the chain of survival concept for out-of-hospital cardiac arrest

BACKGROUND

The American Heart Association 2010 resuscitation guidelines recommended adding a fifth link (multidisciplinary postresuscitation care in a regional center) to the previous 4 in the chain of survival concept for out-of-hospital cardiac arrest. Our study aimed to determine the effectiveness of this fifth link.

METHODS AND RESULTS

This multicenter prospective cohort study involved all eligible out-of-hospital cardiac arrest patients in the Aizu region (n=1482, suburban/rural, Fukushima, Japan). Proportions of favorable neurological outcomes were evaluated before (January 2006-April 2008) and after (January 2009-December 2010) the implementation of the fifth link. After implementation, all patients were transported directly from the field to the tertiary-level hospital or secondarily from an outlying hospital to the tertiary-level hospital after restoration of circulation. The tertiary hospital provided intensive postresuscitation care, including appropriate hemodynamic and respiratory management, therapeutic hypothermia, and percutaneous coronary intervention. One-month survival with a favorable neurological outcome among all patients treated by emergency medical services providers improved significantly after implementation (4 of 770 [0.5%] versus 21 of 712 [3.0%]; P<0.001). The adjusted odds ratios of favorable neurological outcome were 0.9 (95% confidence interval, 0.7-1.1) for early access to emergency medical care, 3.1 (95% confidence interval, 0.7-14.2) for bystander resuscitation, 14.7 (95% confidence interval, 3.2-67.0) for early defibrillation, 1.0 (95% confidence interval, 1.0-1.1) for early advanced life support, and 7.8 (95% confidence interval, 1.6-39.0) for the fifth link.

CONCLUSION

The proportion of out-of-hospital cardiac arrest patients with a favorable neurological outcome improved significantly after the implementation of the fifth link, which may be an independent predictor of outcome.

CLINICAL TRIAL REGISTRATION

URL: http://www.apps.who.int/trialsearch. Unique identifier: UMIN000001607.

Paediatric trauma mortality in Norway: a population-based study of injury characteristics and urban-rural differences

INTRODUCTION

Paediatric injury is a major global public health challenge. Epidemiological research is required for effective primary injury prevention and to develop trauma systems for optimal management of childhood injuries. This study aimed to describe the characteristics and geographical distribution of paediatric trauma deaths and to assess the relationship between rural locations and mortality rates.

MATERIALS AND METHODS

By accessing national registries, all trauma related deaths of persons aged 0-15 years in Norway from 1998 to 2007 were included. Paediatric trauma mortality rates and injury characteristic were analysed in relation to three different measures of municipal rurality: centrality, population density and settlement density.

RESULTS

There were 462 trauma related deaths during the study period and the national annual paediatric mortality rate was 4.81/100000. Rural areas had higher mortality rates, and this difference was best predicted by municipal centrality. Rural trauma was characterised by traffic accidents and deaths that occurred prior to reaching hospital. The rural and northernmost county, Finnmark, had a mortality rate three times the national average.

CONCLUSION

Mortality rates after childhood injury are high in rural areas. Substantiated measures of rurality are required for optimal allocation of primary and secondary preventive measures.

Use of cardiocerebral resuscitation or AHA/ERC 2005 Guidelines is associated with improved survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis

OBJECTIVE

To determine whether the use of cardiocerebral resuscitation (CCR) or AHA/ERC 2005 Resuscitation Guidelines improved patient outcomes from out-of-hospital cardiac arrest (OHCA) compared to older guidelines.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, Web of Science and the Cochrane Library databases. We also hand-searched study references and consulted experts.

STUDY SELECTION

Design: randomised controlled trials and observational studies.

POPULATION

OHCA patients, age >17 years.

COMPARATORS

'Control' protocol versus 'Study' protocol. 'Control' protocol defined as AHA/ERC 2000 Guidelines for cardiopulmonary resuscitation (CPR). 'Study' protocol defined as AHA/ERC 2005 Guidelines for CPR, or a CCR protocol.

OUTCOME

Survival to hospital discharge.

QUALITY

High-quality or medium-quality studies, as measured by the Newcastle Ottawa Scale using predefined categories.

RESULTS

Twelve observational studies met inclusion criteria. All the three studies using CCR demonstrated significantly improved survival compared to use of AHA 2000 Guidelines, as did five of the nine studies using AHA/ERC 2005 Guidelines. Pooled data demonstrate that use of a CCR protocol has an unadjusted OR of 2.26 (95% CI 1.64 to 3.12) for survival to hospital discharge among all cardiac arrest patients. Among witnessed ventricular fibrillation/ventricular tachycardia (VF/VT) patients, CCR increased survival by an OR of 2.98 (95% CI 1.92 to 4.62). Studies using AHA/ERC 2005 Guidelines showed an overall trend towards increased survival, but significant heterogeneity existed among these studies.

CONCLUSIONS

We demonstrate an association with improved survival from OHCA when CCR protocols or AHA/ERC 2005 Guidelines are compared to use of older guidelines. In the subgroup of patients with witnessed VF/VT, there was a threefold increase in OHCA survival when CCR was used. CCR appears to be a promising resuscitation protocol for Emergency Medical Services providers in increasing survival from OHCA. Future research will need to be conducted to directly compare AHA/ERC 2010 Guidelines with the CCR approach.

Regional variations in early and late survival after out-of-hospital cardiac arrest

BACKGROUND

While prior studies highlight regional variations in out-of-hospital cardiac arrest (OHCA) survival, the underlying reasons remain unknown. We sought to characterize regional variations early and later survival to hospital discharge after OHCA.

METHODS

We studied adult, non-traumatic OHCA treated by 10 regional sites of the Resuscitation Outcomes Consortium (ROC) during 12/01/2005-6/30/2007. We compared (1) early survival (up to one calendar day after arrest) and (2) later conditional survival to hospital discharge (early survivors progressing to eventual hospital discharge) between ROC regional sites.

RESULTS

Among 3763 VF/VT with complete covariates, site unadjusted early survival varied from 11.3 to 54.3%, and site unadjusted later survival varied from 33.3 to 70.5%. Compared with the largest site, adjusted VF/VT survival varied across sites: early survival OR 0.33 (95% CI: 0.17, 0.65) to 2.87 (2.20, 3.73), overall site variation p<0.001; later survival OR 0.29 (0.14, 0.59) to 1.21 (0.73, 2.00), p<0.001. Among 10,879 non-VF/VT with complete covariates, site unadjusted early survival varied from 6.6 to 14.3%, and site unadjusted later survival varied from 4.5 to 39.6%. Compared with the largest site, adjusted non-VF/VT survival varied across sites: early survival OR 1.02 (0.63, 1.64) to 2.43 (1.91, 3.12), p<0.001; later survival OR 0.11 (0.01, 0.82) to 1.56 (0.90, 2.70), p=0.02.

CONCLUSIONS

In this prospective multicenter North American series, there were regional disparities in early and later survival after OHCA, suggesting that there are underlying regional differences in out-of-hospital and post-arrest care beyond traditional Utstein predictors. Community efforts to improve OHCA survival must address both out-of-hospital and in-hospital care.

Cardiopulmonary resuscitation and management of cardiac arrest

The best chance of survival with a good neurological outcome after cardiac arrest is afforded by early recognition and high-quality cardiopulmonary resuscitation (CPR), early defibrillation of ventricular fibrillation (VF), and subsequent care in a specialist center. Compression-only CPR should be used by responders who are unable or unwilling to perform mouth-to-mouth ventilations. After the first defibrillator shock, further rhythm checks and defibrillation attempts should be performed after 2 min of CPR. The underlying cause of cardiac arrest can be identified and treated during CPR. Drugs have a limited effect on long-term outcomes after cardiac arrest, although epinephrine improves the success of resuscitation, and amiodarone increases the success of defibrillation for refractory VF. Supraglottic airway devices are an alternative to tracheal intubation, which should be attempted only by skilled rescuers. Care after cardiac arrest includes controlled reoxygenation, therapeutic hypothermia for comatose survivors, percutaneous coronary intervention, circulatory support, and control of blood-glucose levels and seizures. Prognostication in comatose survivors of cardiac arrest needs a careful, multimodal approach using clinical and electrophysiological assessments after at least 72 h.

Engaging a whole community in resuscitation

BACKGROUND

Survival after out-of-hospital cardiac arrest (OHCA) is influenced by each link in the chain of survival. On the Danish island of Bornholm (population 42,000, area 588 km2) none survived an OHCA in 2001-2003. Therefore, we designed a multifaceted community-based approach aiming at strengthening each link in the chain of survival. The purpose of this study was to evaluate the effect of implementation of the intervention on bystander basic life support (BLS) rates and survival to hospital discharge after OHCA.

METHODS

Laypersons completed 24-min DVD-based-self-instruction BLS courses in schools and workplaces or 4-h BLS/automated external defibrillator (AED) courses. The local television station had broadcasts about resuscitation. The ambulance personnel were trained and the staff at the island hospital completed BLS courses or more advanced courses.

RESULTS

During 2 years 9226 people (22% of the population) completed the short course and 2453 (6% of the population) completed the 4-h course. The number of AEDs increased from 3 to 147. The bystander BLS rate for OHCAs with a presumed cardiac aetiology (N=96, incidence 114/100,000 person-years) was 47% [95% CI 30-50] and for witnessed OHCAs (N=35) it increased significantly from 22% (2004) to 74% [95% CI 58-86]. The AEDs were deployed in 9 cases. Survival to discharge for all-rhythms OHCA was 5.4% [95% CI 2-12], and for witnessed ventricular fibrillation (N=17) 18% [95% CI 5-42].

CONCLUSION

Strengthening all links in the chain of survival was associated with significant increases in bystander BLS rates and survival after OHCA on a rural island.

Optimizing outcome after cardiac arrest

PURPOSE OF REVIEW

To discuss recent data relating to survival rates after cardiac arrest and interventions that can be used to optimize outcome.

RECENT FINDINGS

A recent analysis of 70 studies indicates that following out-of-hospital cardiac arrest (OHCA), 7.6% of patients will survive to hospital discharge (95% confidence interval 6.7-8.4). Following in-hospital cardiac arrest, 18% of patients will survive to hospital discharge. Survival may be optimized by increasing the rate of bystander cardiopulmonary resuscitation (CPR), which can be achieved by improving recognition of cardiac arrest, simplifying CPR and training more of the community. Feedback systems improve the quality of CPR but this has yet to be translated into improved outcome. One study has shown improved survival following OHCA with active compression-decompression CPR combined with an impedance-threshold device. In those who have no obvious extracardiac cause of OHCA, 70% have at least one significant coronary lesion demonstrable by coronary angiography. Although generally reserved for those with ST-elevation myocardial infarction, primary percutaneous coronary intervention may also benefit OHCA survivors with ECG patterns other than ST elevation. The term 'mild therapeutic hypothermia' has been replaced by the term 'targeted temperature management'; its role in optimizing outcome after cardiac arrest continues to be defined.

SUMMARY

In several centres, survival rates following OHCA are increasing. All links in the chain of survival must be optimized if a good-quality neurological outcome is to be achieved.

Increasing hospital volume is not associated with improved survival in out of hospital cardiac arrest of cardiac etiology

BACKGROUND

Resuscitation centers may improve patient outcomes by achieving sufficient experience in post-resuscitation care. We analyzed the relationship between survival and hospital volume among patients suffering out-of-hospital cardiac arrest (OHCA).

METHODS

This prospective cohort investigation collected data from the Cardiac Arrest Registry to Enhance Survival database from 10/1/05 to 12/31/09. Primary outcome was survival to discharge. Hospital characteristics were obtained via 2005 American Hospital Association Survey. A hospital's use of hypothermia was obtained via direct survey. To adjust for hospital- and patient-level variation, multilevel, hierarchical logistic regression was performed. Hospital volume was modeled as a categorical (OHCA/year≤10, 11-39, ≥40) variable. A stratified analysis evaluating those with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) was also performed.

RESULTS

The cohort included 4125 patients transported by EMS to 155 hospitals in 16 states. Overall survival to hospital discharge was 35% among those admitted to the hospital. Individual hospital rates of survival varied widely (0-100%). Unadjusted survival did not differ between the 3 hospital groups (36% for ≤10 OHCA/year, 35% for 11-39, and 36% for ≥40; p=0.75). After multilevel adjustment, differences in survival across the groups were not statistically significant. Compared to patients at hospitals with ≤10 OHCA/year, adjusted OR for survival was 1.04 (CI(95) 0.83-1.28) among 11-39 annual volume and 0.97 (CI(95) 0.73-1.30) among the ≥40 volume hospitals. Among patients presenting with VF/VT, no difference in survival was identified between the hospital groups.

CONCLUSION

Survival varied substantially across hospitals. However, hospital OHCA volume was not associated with likelihood of survival. Additional efforts are required to determine what hospital characteristics might account for the variability observed in OHCA hospital outcomes.

"Putting it all together" to improve resuscitation quality

Solutions to improve care provided during cardiac arrest resuscitation attempts must be multifaceted and targeted to the diverse number of care providers to be successful. In this article, new approaches to improving cardiac arrest resuscitation performance are reviewed. The focus is on a continuous quality improvement paradigm highlighting improving training methods before actual cardiac arrest events, monitoring quality during resuscitation attempts, and using quantitative debriefing programs after events to educate frontline care providers.

Regional impact of cardiac arrest center criteria on out-of-hospital transportation practices

BACKGROUND

Cardiac arrest center (CAC) criteria are not well defined, nor is their potential impact on current emergency medical services (EMS) transportation practices for post-cardiac arrest (PCA) patients. In addition to the availability of emergent cardiac catheterization (CATH) and therapeutic hypothermia (TH), high-volume centers and those with PCA protocols have been associated with improved outcomes. Objectives. This study aimed 1) to identify the PCA treatment capabilities of receiving hospitals in a 10-county regional EMS system without official CAC designation and 2) to determine the proportion of PCA patients who are transported to hospitals meeting three proposed CAC definitions. We hypothesized that a majority of patients are already transported to hospitals that meet proposed CAC criteria.

METHODS

We distributed a survey to 34 receiving hospitals to determine availability and volume of CATH, TH, a PCA protocol, and a 24-hour intensivist. We conducted a retrospective study of adult, nontrauma cardiac arrest patients transported with a pulse from 2006 to 2008 for 16 EMS agencies. The proportions of patients transported to hospitals meeting three CAC criteria were compared: criteria A (availability of CATH and TH), criteria B (criteria A, >200 CATHs per year, and a PCA protocol), and criteria C (criteria B and a 24-hour intensivist).

RESULTS

Data were obtained from 31 of 34 hospitals (91.1%), of which 10 (32.3%) met criteria A, seven (22.6%) met criteria B, and six (19.4%) met criteria C. Of 1,193 cardiac arrest patients, 46 (3.9%) were excluded because of transport to a pediatric, closed, or out-of-region hospital. There were 335 patients (81.1%) with return of spontaneous circulation and a pulse present upon arrival at the destination facility transported to hospitals meeting criteria A, 304 patients (73.6%) transported to hospitals meeting criteria B, and 273 patients (66.1%) transported to hospitals meeting criteria C.

CONCLUSIONS

In a region without official CAC designation, only one-third of hospitals meet basic CAC criteria (CATH and TH), but those facilities receive 81% of PCA patients. Fewer patients (66%) are transported to hospitals meeting more stringent CAC criteria. These data describe the potential impact of developing a CAC policy based on current transportation practices.