Does care at a cardiac arrest centre improve outcome after out-of-hospital cardiac arrest? - A systematic review

Cardiac arrest and post-discharge mortality in patients with myocardial infarction: A large-scale nationwide registry analysis

Background

Cardiac arrest is a serious complication of acute myocardial infarction. The implementation of contemporary approaches to acute myocardial infarction management, including urgent revascularization procedures, has led to significant improvements in short-term outcomes. However, the extent of post-discharge mortality in patients experiencing cardiac arrest during acute myocardial infarction remains uncertain. This study aimed to determine the post-discharge outcomes of patients with cardiac arrest.

Methods

We analysed data from the J-PCI OUTCOME registry, a Japanese prospectively planed, observational, multicentre, national registry of percutaneous coronary intervention involving consecutive patients from 172 institutions who underwent percutaneous coronary intervention and were discharged. Patients who underwent percutaneous coronary intervention for acute myocardial infarction between January 2017 and December 2018 and survived for 30 days were included. Mortality in patients with and without cardiac arrest from 30 days to 1 year after percutaneous coronary intervention for acute myocardial infarction was compared.

Results

Of the 26,909 patients who survived for 30 days after percutaneous coronary intervention for acute myocardial infarction, 1,567 (5.8%) had cardiac arrest at the onset of acute myocardial infarction. Patients with cardiac arrest were younger and more likely to be males than patients without cardiac arrest. The 1-year all-cause mortality was significantly higher in patients with cardiac arrest than in those without (11.9% vs. 2.8%, p < 0.001) for all age groups. Multivariable analysis showed that cardiac arrest was an independent predictor of all-cause long-term mortality (hazard ratio: 2.94; 95% confidence interval: 2.29-3.76).

Conclusions

Patients with acute myocardial infarction and concomitant cardiac arrest have a worse prognosis for up to 1 year after percutaneous coronary intervention than patients without cardiac arrest.

Out-of-Hospital Cardiac Arrest

Survival from out-of-hospital cardiac arrest (OHCA) is predicated on a community and system-wide approach that includes rapid recognition of cardiac arrest, capable bystander CPR, effective basic and advanced life support (BLS and ALS) by EMS providers, and coordinated postresuscitation care. Management of these critically ill patients continues to evolve. This article focuses on the management of OHCA by EMS providers.

Nursing core competencies for postresuscitation care in Iran: a qualitative study

OBJECTIVE

This study explored nurses' perceptions of the core competencies required for providing postresuscitation care in both in-hospital and out-of-hospital cardiac arrest.

DESIGN

Qualitative conventional content analysis.

PARTICIPANTS

17 nurses selected with purposeful sampling method.

SETTING

Three educational hospitals in northwest of Iran.

DATA COLLECTION AND ANALYSIS

Semi-structured interviews were used for data collection and they were analysed using conventional content analysis.

RESULTS

Seven main categories have emerged from the data. The core competencies for nurses providing postresuscitation were identified as: quality assurance, providing evidence-based care, monitoring and presence, situation management, professionalism, positive attitude and providing family centred care.

CONCLUSIONS

The postresuscitation period is a unique and critical time requiring highly competent nursing care. Several core competencies for providing high-quality nursing care during postresuscitation period were identified through nurses' experience in caring for patients postresuscitation.

Association between institutional volume of out-of-hospital cardiac arrest cases and short term outcomes

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a serious condition. The volume-outcome relationship and various post-cardiac arrest care elements are believed to be associated with improved neurological outcomes. Although previous studies have investigated the volume-outcome relationship, adjusting for post-cardiac arrest care, intra-class correlation for each institution, and other covariates may have been insufficient.

OBJECTIVE

To investigate the volume-outcome relationships and favorable neurological outcomes among OHCA cases in each institution.

METHODS

We conducted a prospective observational study of adult patients with non-traumatic OHCA using the OHCA registry in Japan. The primary outcome was 30-day favorable neurological outcomes, and the secondary outcome was 30-day survival. We set the cutoff values to trisect the number of patients as equally as possible and classified institutions into high-, middle-, and low-volume. Generalized estimating equations (GEE) were performed to adjust for covariates and within-hospital clustering.

RESULTS

Among the 9909 registry patients, 7857 were included. These patients were transported to either low- (2679), middle- (2657), or high- (2521) volume institutions. The median number of eligible patients per institution in 19 months of study periods was 82 (range, 1-207), 252 (range, 210-353), and 463 (range, 390-701), respectively. After multivariable GEE using the low-volume institution as a reference, no significant difference in odds ratios and 95% confidence intervals were noted for 30-day favorable neurological outcomes for middle volume [1.22 (0.69-2.17)] and high volume [0.80 (0.47-1.37)] institutions. Moreover, there was no significant difference for 30-day survival for middle volume [1.02 (0.51-2.02)] and high volume [1.09 (0.53-2.23)] institutions.

CONCLUSION

The patient volume of each institution was not associated with 30-day favorable neurological outcomes. Although this result needs to be evaluated more comprehensively, there may be no need to set strict requirements for the type of institution when selecting a destination for OHCA cases.

Early and late withdrawal of life-sustaining treatment after out-of-hospital cardiac arrest in the United Kingdom: Institutional variation and association with hospital mortality

AIM

Frequency and timing of Withdrawal of Life-Sustaining Treatment (WLST) after Out-of-Hospital Cardiac Arrest (OHCA) vary across Intensive Care Units (ICUs) in the United Kingdom (UK) and may be a marker of lower healthcare quality if instituted too frequently or too early. We aimed to describe WLST practice, quantify its variability across UK ICUs, and assess the effect of institutional deviation from average practice on patients' risk-adjusted hospital mortality.

METHODS

We conducted a retrospective multi-centre cohort study including all adult patients admitted after OHCA to UK ICUs between 2010 and 2017. We identified patient and ICU characteristics associated with early (within 72 h) and late (>72 h) WLST and quantified the between-ICU variation. We used the ICU-level observed-to-expected (O/E) ratios of early and late-WLST frequency as separate metrics of institutional deviation from average practice and calculated their association with patients' hospital mortality.

RESULTS

We included 28,438 patients across 204 ICUs. 10,775 (37.9%) had WLST and 6397 (59.4%) of them had early-WLST. Both WLST types were strongly associated with patient-level demographics and pre-existing conditions but weakly with ICU-level characteristics. After adjustment, we found unexplained between-ICU variation for both early-WLST (Median Odds Ratio 1.59, 95%CrI 1.49-1.71) and late-WLST (MOR 1.39, 95%CrI 1.31-1.50). Importantly, patients' hospital mortality was higher in ICUs with higher O/E ratio of early-WLST (OR 1.29, 95%CI 1.21-1.38, p < 0.001) or late-WLST (OR 1.39, 95%CI 1.31-1.48, p < 0.001).

CONCLUSIONS

Significant variability exists between UK ICUs in WLST frequency and timing. This matters because unexplained higher-than-expected WLST frequency is associated with higher hospital mortality independently of timing, potentially signalling prognostic pessimism and lower healthcare quality.

Out-of-Hospital Cardiac Arrest

Survival from out-of-hospital cardiac arrest (OHCA) is predicated on a community and system-wide approach that includes rapid recognition of cardiac arrest, capable bystander CPR, effective basic and advanced life support (BLS and ALS) by EMS providers, and coordinated postresuscitation care. Management of these critically ill patients continues to evolve. This article focuses on the management of OHCA by EMS providers.

Cardiac arrest centres: what do they add?

There are wide regional variations in outcome following resuscitated out of hospital cardiac arrest. These geographical differences appear to be due to hospital infrastructure and provider experience rather than baseline characteristics. It is proposed that post-arrest care be delivered in a systematic fashion by concentrating services in Cardiac Arrest Centres, with greater provider experience, 24-hour access to diagnostics, and specialist treatment to minimise the impact of ischaemia-reperfusion injury and treat the causative pathology. These cardiac arrest centres would provide access to targeted critical care, acute cardiac care, radiology services and appropriate neuro-prognostication. However implementation of cardiac arrest networks with specialist receiving hospitals is complex and requires alignment of pre-hospital care services with those delivered in hospital. Furthermore there are no randomised trial data currently supporting pre-hospital delivery to a Cardiac Arrest Centre and definitions are heterogeneous. In this review article, we propose a universal definition of a Cardiac Arrest Centre and review the current observational data evidence and the potential impact of the ARREST trial.

The development of a risk-adjustment strategy to benchmark emergency medical service (EMS) performance in relation to out-of-hospital cardiac arrest in Australia and New Zealand

INTRODUCTION

The aim of this study was to develop a risk adjustment strategy, including effect modifiers, for benchmarking emergency medical service (EMS) performance for out-of-hospital cardiac arrest (OHCA) in Australia and New Zealand.

METHOD

Using 2017-2019 data from the Australasian Resuscitation Outcomes Consortium (Aus-ROC) OHCA Epistry, we included adults who received an EMS attempted resuscitation for a presumed medical OHCA. Logistic regression was applied to develop risk adjustment models for event survival (return of spontaneous circulation at hospital handover) and survival to hospital discharge/30 days. We examined potential effect modifiers, and assessed model discrimination and validity.

RESULTS

Both OHCA survival outcome models included EMS agency and the Utstein variables (age, sex, location of arrest, witnessed arrest, initial rhythm, bystander cardiopulmonary resuscitation, defibrillation prior to EMS arrival, and EMS response time). The model for event survival had good discrimination according to the concordance statistic (0.77) and explained 28% of the variation in survival. The corresponding figures for survival to hospital discharge/30 days were 0.87 and 49%. The addition of effect modifiers did little to improve the performance of either model.

CONCLUSION

The development of risk adjustment models with good discrimination is an important step in benchmarking EMS performance for OHCA. The Utstein variables are important in risk-adjustment, but only explain a small proportion of the variation in survival. Further research is required to understand what factors contribute to the variation in survival between EMS.

Developments in Post-Resuscitation Care for Out-of-Hospital Cardiac Arrests in Adults-A Narrative Review

This review focuses on current developments in post-resuscitation care for adults with an out-of-hospital cardiac arrest (OHCA). As the incidence of OHCA is high and with a low percentage of survival, it remains a challenge to treat those who survive the initial phase and regain spontaneous circulation. Early titration of oxygen in the out-of-hospital phase is not associated with increased survival and should be avoided. Once the patient is admitted, the oxygen fraction can be reduced. To maintain an adequate blood pressure and urine output, noradrenaline is the preferred agent over adrenaline. A higher blood pressure target is not associated with higher rates of good neurological survival. Early neuro-prognostication remains a challenge, and prognostication bundles should be used. Established bundles could be extended by novel biomarkers and methods in the upcoming years. Whole blood transcriptome analysis has shown to reliably predict neurological survival in two feasibility studies. This needs further investigation in larger cohorts.

Management of comatose survivors of out-of-hospital cardiac arrest in Europe: current treatment practice and adherence to guidelines. A joint survey by the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Resuscitation Council (ERC), the European Society for Emergency Medicine (EUSEM), and the European Society of Intensive Care Medicine (ESICM)

AIMS

International guidelines give recommendations for the management of comatose out-of-hospital cardiac arrest (OHCA) survivors. We aimed to investigate adherence to guidelines and disparities in the treatment of OHCA in hospitals in Europe.

METHODS AND RESULTS

A web-based, multi-institutional, multinational survey in Europe was conducted using an electronic platform with a predefined questionnaire developed by experts in post-resuscitation care. The survey was disseminated to all members of the societies via email, social media, websites, and newsletters in June 2021. Of 252 answers received, 237 responses from different units were included and 166 (70%) were from cardiac arrest centres. First-line vasopressor used was noradrenaline in 195 (83%) and the first-line inotrope was dobutamine in 148 (64%) of the responses. Echocardiography is available 24/7 in 204 (87%) institutions. Targeted temperature management was used in 160 (75%) institutions for adult comatose survivors of OHCA with an initial shockable rhythm. Invasive or external cooling methods with feedback were used in 72 cardiac arrest centres (44%) and 17 (24%) non-cardiac arrest centres (P < 0.0003). A target temperature between 32 and 34°C was preferred by 46 centres (21%); a target between 34 and 36°C by 103 centres (52%); and <37.5°C by 35 (16%). Multimodal neuroprognostication was poorly implemented and a follow-up at 3 months after discharge was done in 71 (30%) institutions.

CONCLUSION

Post-resuscitation care is not well established and varies among centres in European hospitals. Cardiac arrest centres have a higher coherence with guidelines compared with respondents from non-cardiac arrest centres. The overall inconsistency in approaches and deviation from recommendations could be a focus for improvement.

Coronary angiography in patients without ST-segment elevation following out-of-hospital cardiac arrest. COUPE clinical trial

INTRODUCTION AND OBJECTIVES

The role of emergency coronary angiography (CAG) and percutaneous coronary intervention (PCI) following out-of-hospital cardiac arrest (OHCA) in patients without ST-segment elevation myocardial infarction (STEMI) remains unclear. We aimed to assess whether emergency CAG and PCI would improve survival with good neurological outcome in this population.

METHODS

In this multicenter, randomized, open-label, investigator-initiated clinical trial, we randomly assigned 69 survivors of OHCA without STEMI to undergo immediate CAG or deferred CAG. The primary efficacy endpoint was a composite of in-hospital survival free of severe dependence. The safety endpoint was a composite of major adverse cardiac events including death, reinfarction, bleeding, and ventricular arrhythmias.

RESULTS

A total of 66 patients were included in the primary analysis (95.7%). In-hospital survival was 62.5% in the immediate CAG group and 58.8% in the delayed CAG group (HR, 0.96; 95%CI, 0.45-2.09; P=.93). In-hospital survival free of severe dependence was 59.4% in the immediate CAG group and 52.9% in the delayed CAG group (HR, 1.29; 95%CI, 0.60-2.73; P=.4986). No differences were found in the secondary endpoints except for the incidence of acute kidney failure, which was more frequent in the immediate CAG group (15.6% vs 0%, P=.002) and infections, which were higher in the delayed CAG group (46.9% vs 73.5%, P=.003).

CONCLUSIONS

In this underpowered randomized trial involving patients resuscitated after OHCA without STEMI, immediate CAG provided no benefit in terms of survival without neurological impairment compared with delayed CAG.

CLINICALTRIALS

gov Identifier: NCT02641626.

Correspondence: is there an association between centre volume and survival or neurological outcomes among out-of-hospital cardiac arrest patients?

This commentary discusses the findings of a study by Tsuchida et al. on the effect of annual hospital admissions of out-of-hospital cardiac arrest patients on survival and neurological outcomes in OHCA patients in the context of existing literature on the topic, and the implications on future studies investigating the volume-outcome relationship in cardiac arrest.

British Cardiovascular Interventional Society Consensus Position Statement on Out-of-Hospital Cardiac Arrest 1: Pathway of Care

Out-of-hospital cardiac arrest (OHCA) affects 80,000 patients per year in the UK; despite improvements in care, survival to discharge remains lower than 10%. NHS England and several societies recommend all resuscitated OHCA patients be directly transferred to a cardiac arrest centre (CAC). However, evidence is limited that all patients benefit from transfer to a CAC, and there are significant organisational, logistic and financial implications associated with such change in policies. Furthermore, there is significant variability in interventional cardiovascular practices for OHCA. Accordingly, the British Cardiovascular Interventional Society established a multidisciplinary group to address variability in practice and provide recommendations for the development of cardiac networks. In this position statement, we recommend: the formal establishment of dedicated CACs; a pathway of conveyance to CACs; and interventional practice to standardise our approach. Further research is needed to understand the role of CACs and which interventions benefit patients with OHCA to support wide-scale changes in networks of care across the UK.

Cardiac Arrest Center – Zertifizierung stärkt Patientenzufluss durch den Rettungsdienst

Hintergrund

Seit 2015 empfehlen die internationalen Reanimationsleitlinien die Implementierung von spezialisierten Krankenhäusern (sog. Cardiac Arrest Center, CAC) für die Versorgung von Patienten mit außerklinischem Herz-Kreislauf-Stillstand.

Ziel

Ziel der Studie war es, den potenziellen Einfluss der Zertifizierung von Kliniken als CAC auf das Einweisungsverhalten von Notärzten und Rettungsfachpersonal bei prähospital reanimierten Patienten zu untersuchen.

Methoden

Eine webbasierte anonyme Befragung mit 20 Items wurde vom 15.05. bis zum 15.06.2018 in Deutschland durchgeführt. Zielgruppen waren im Rettungsdienst tätige Notärzte sowie Rettungsfachpersonal.

Wesentliche Ergebnisse

Von 437 Teilnehmern wurden die Ergebnisse von 378 Befragten (n = 292 Notärzte, n = 86 Rettungsfachpersonen) in die statistische Analyse eingeschlossen. 75,1 % (n = 284) gaben an, dass die CAC-Zertifizierung von Krankenhäusern bei ihrem künftigen Einweisungsverhalten von Patienten mit präklinischem Herz-Kreislauf-Stillstand eine Rolle spielen würde. 78,3 % (n = 296) erwarteten, dass die CAC-Zertifizierung zu einer Verbesserung der Patientenversorgung führen wird. 78,8 % (n = 298) befürworteten die Einführung der CAC-Zertifizierung. Die Befragten würden eine zusätzliche Transportzeit von 16,3 min (95 %-KI: 15,2–17,3) akzeptierten, um ein CAC zu erreichen.

Fazit

Die Zertifizierung von Kliniken als CAC hat das Potenzial, die Entscheidung des Rettungsdienstpersonals bei der Zuweisung von Patienten mit einem präklinischen Herz-Kreislauf-Stillstand zu beeinflussen. Aufgrund der limitierten zusätzlich akzeptablen Transportzeit zur Erreichung eines CAC bedarf es eines bundesweiten, engen Netzes zertifizierter Kliniken.

Effect of annual hospital admissions of out-of-hospital cardiac arrest patients on prognosis following cardiac arrest

Background

Although the prognosis of patients treated at specialized facilities has improved, the relationship between the number of patients treated at hospitals and prognosis is controversial and lacks constancy in those with out-of-hospital cardiac arrest (OHCA). This study aimed to clarify the effect of annual hospital admissions on the prognosis of adult patients with OHCA by analyzing a large cohort.

Methods

The effect of annual hospital admissions on patient prognosis was analyzed retrospectively using data from the Japanese Association for Acute Medicine OHCA registry, a nationwide multihospital prospective database. This study analyzed 3632 of 35,754 patients hospitalized for OHCA of cardiac origin at 86 hospitals. The hospitals were divided into tertiles based on the volume of annual admissions. The effect of hospital volume on prognosis was analyzed using logistic regression analysis with multiple imputation. Furthermore, three subgroup analyses were performed for patients with return of spontaneous circulation (ROSC) before arrival at the emergency department, patients admitted to critical care medical centers, and patients admitted to extracorporeal membrane oxygenation-capable hospitals.

Results

Favorable neurological outcomes 30 days after OHCA for patients overall showed no advantage for medium- and high-volume centers over low-volume centers; Odds ratio (OR) 0.989, (95% Confidence interval [CI] 0.562-1.741), OR 1.504 (95% CI 0.919-2.463), respectively. However, the frequency of favorable neurological outcomes in OHCA patients with ROSC before arrival at the emergency department at high-volume centers was higher than those at low-volume centers (OR 1.955, 95% CI 1.033-3.851).

Conclusion

Hospital volume did not significantly affect the prognosis of adult patients with OHCA. However, transport to a high-volume hospital may improve the neurological prognosis in OHCA patients with ROSC before arrival at the emergency department.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00685-7.

Cardiac arrest centres: what, who, when, and where?

PURPOSE OF REVIEW

Cardiac arrest centres (CACs) may play a key role in providing postresuscitation care, thereby improving outcomes in out-of-hospital cardiac arrest (OHCA). There is no consensus on CAC definitions or the optimal CAC transport strategy despite advances in research. This review provides an updated overview of CACs, highlighting evidence gaps and future research directions.

RECENT FINDINGS

CAC definitions vary worldwide but often feature 24/7 percutaneous coronary intervention capability, targeted temperature management, neuroprognostication, intensive care, education, and research within a centralized, high-volume hospital. Significant evidence exists for benefits of CACs related to regionalization. A recent meta-analysis demonstrated clearly improved survival with favourable neurological outcome and survival among patients transported to CACs with conclusions robust to sensitivity analyses. However, scarce data exists regarding 'who', 'when', and 'where' for CAC transport strategies. Evidence for OHCA patients without ST elevation postresuscitation to be transported to CACs remains unclear. Preliminary evidence demonstrated greater benefit from CACs among patients with shockable rhythms. Randomized controlled trials should evaluate specific strategies, such as bypassing nearest hospitals and interhospital transfer.

SUMMARY

Real-world study designs evaluating CAC transport strategies are needed. OHCA patients with underlying culprit lesions, such as those with ST-elevation myocardial infarction (STEMI) or initial shockable rhythms, will likely benefit the most from CACs.

Resuscitation guideline highlights

PURPOSE OF REVIEW

The purpose of this review was to give an overview of the most significant updates in resuscitation guidelines and provide some insights into the new topics being considered in upcoming reviews.

RECENT FINDINGS

Recent updates to resuscitation guidelines have highlighted the importance of the earlier links in the chain-of-survival aimed to improve early recognition, early cardiopulmonary resuscitation (CPR) and defibrillation. Empowering lay rescuers with the support of emergency medical dispatchers or telecommunicators and engaging the community through dispatching volunteers and Automated External Defibrillators, are considered key in improving cardiac arrest outcomes. Novel CPR strategies such as passive insufflation and head-up CPR are being explored, but lack high-certainty evidence. Increased focus on survivorship also highlights the need for more evidence based guidance on how to facilitate the necessary follow-up and rehabilitation after cardiac arrest. Many of the systematic and scoping reviews performed within cardiac arrest resuscitation domains identifies significant knowledge gaps on key elements of our resuscitation practices. There is an urgent need to address these gaps to further improve survival from cardiac arrest in all settings.

SUMMARY

A continuous evidence evaluation process for resuscitation after cardiac arrest is triggered by new evidence or request by the resuscitation community, and provides more current and relevant guidance for clinicians.

Global variation in the incidence and outcome of emergency medical services witnessed out-of-hospital cardiac arrest: A systematic review and meta-analysis

AIM OF THE REVIEW

To examine global variation in the incidence and outcomes of emergency medical services (EMS) witnessed out-of-hospital cardiac arrest (OHCA).

DATA SOURCES

We systematically reviewed four electronic databases for studies between 1990 and 5th April 2021 reporting EMS-witnessed OHCA populations. Studies were included if they reported sufficient data to calculate the primary outcome of survival to hospital discharge or 30-day survival. Random-effects models were used to pool incidence and survival outcomes, and meta-regression was used to examine sources of heterogeneity. Study quality was appraised using the Joanna Briggs Institute critical appraisal tools.

RESULTS

The search returned 1178 non-duplicate titles of which 66 articles comprising 133,981 EMS-witnessed patients treated by EMS across 33 countries were included. All but one study was observational and only 12 studies (18%) were deemed to be at low risk of bias. The pooled incidence of EMS-treated cases was 4.1 per 100,000 person-years (95% CI: 3.5, 4.7), varying almost 4-fold across continents. The pooled proportion of survivors to hospital discharge or 30-days was 20% overall (95% CI: 18%, 22%; I² = 98%), 43% (95% CI: 37%, 49%; I² = 94%) for initial shockable rhythms and 6% (95% CI: 5%, 8%; I² = 79%) for initial non-shockable rhythms. In the meta-regression analysis, only region and aetiology were significantly associated with survival. When compared to studies from North America, pooled survival was significantly higher in studies from Europe (14% vs. 26%; p = 0.04) and Australasia (14% vs. 31%, p < 0.001).

CONCLUSION

We identified significant global variation in the incidence and survival outcome of EMS-witnessed OHCA. Further research is needed to understand the factors contributing to these variations.

Direct Transport to Cardiac Arrest Center and Survival Outcomes after Out-of-Hospital Cardiac Arrest by Urbanization Level

Current guidelines for post-resuscitation care recommend regionalized care at a cardiac arrest center (CAC). Our objectives were to evaluate the effect of direct transport to a CAC on survival outcomes of out-of-hospital cardiac arrests (OHCAs), and to assess interaction effects between CAC and urbanization levels. Adult EMS-treated OHCAs with presumed cardiac etiology between 2015 and 2019 were enrolled. The main exposure was the hospital where OHCA patients were transported by EMS (CAC or non-CAC). The outcomes were good neurological recovery and survival to discharge. Multivariable logistic regression analyses were conducted. Interaction analysis between the urbanization level of the location of arrest (metropolitan or urban/rural area) and the exposure variable was performed. Among the 95,931 study population, 23,292 (24.3%) OHCA patients were transported directly to CACs. Patients in the CAC group had significantly higher likelihood of good neurological recovery and survival to discharge than the non-CAC group (both p < 0.01, aORs (95% CIs): 1.75 (1.63–1.89) and 1.70 (1.60–1.80), respectively). There were interaction effects between CAC and the urbanization level for good neurological recovery and survival to discharge. Direct transport to CAC was associated with significantly better clinical outcomes compared to non-CAC, and the findings were strengthened in OHCAs occurring in nonmetropolitan areas.

Outcomes Following In-Hospital Cardiopulmonary Resuscitation in People Receiving Maintenance Dialysis

Rationale & Objective

Previous studies showing poor cardiopulmonary resuscitation (CPR) outcomes in the dialysis population have largely been derived from claims data and are somewhat limited by a lack of detailed characterization of CPR events. We aimed to analyze CPR-related outcomes in individuals receiving maintenance dialysis.

Study Design

Retrospective chart review.

Setting & Participants

Using electronic medical records from a single academic health care system, we identified all hospitalized adult patients receiving maintenance dialysis who had undergone in-hospital CPR between 2006 and 2014.

Exposure

Initial in-hospital CPR.

Outcomes

Overall survival, predictors of unsuccessful CPR, predictors of death during the same hospitalization among initial survivors, predictors of discharge-to-home status.

Analytical Approach

We provide descriptive statistics for the study variables and used t tests, χ² tests, or Fisher exact tests to compare differences between the groups. We built multivariable logistic regression models to examine the CPR-related outcomes.

Results

A total of 184 patients received in-hospital CPR: 51 (28%) did not survive the initial CPR event, and 77 CPR survivors died (additional 42%) later during the same hospitalization (overall mortality 70%). Only 18 (10%) were discharged home, with the remaining 32 (17%) discharged to a rehabilitation facility or a nursing home. In the multivariable model, the only predictor of unsuccessful CPR was CPR duration (OR, 1.41; 95% CI, 1.24-1.61; P < 0.001). Predictors of death during the same hospitalization after surviving the initial CPR event were CPR duration (OR, 1.15; 95% CI 1.04-1.27; P = 0.007) and older age (OR, 1.64; 95% CI, 1.23-2.2; P < 0.001). Older people also had lower odds of discharge-to-home status (OR, 0.25; 95% CI, 0.11-0.54; P < 0.001).

Limitations

Retrospective study design, single-center study, no information on functional status.

Conclusions

Patients receiving maintenance dialysis experience high mortality following in-hospital CPR and only 10% are discharged home. These data may help clinicians provide useful prognostic information while engaging in goals of care conversations.

Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis

Background

The role of cardiac arrest centers (CACs) in out‐of‐hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out‐of‐hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups.

Methods and Results

Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self‐declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta‐analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty‐six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52–2.26]), even when including high‐volume centers (aOR, 1.50 [95% CI, 1.18–1.91]) or including improved‐care centers (aOR, 2.13 [95% CI, 1.75–2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59–2.32]), even when including high‐volume centers (aOR, 1.74 [95% CI, 1.38–2.18]) or when including improved‐care centers (aOR, 1.97 [95% CI, 1.71–2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm (P=0.006) and without prehospital return of spontaneous circulation (P=0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected.

Conclusions

Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out‐of‐hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.

Basic life support and systems saving lives

PURPOSE OF REVIEW

To describe recent science in basic life support (BLS) after cardiac arrest and how evolving knowledge in resuscitation is changing current guidelines and practices.

RECENT FINDINGS

The core elements of BLS have remained mostly unchanged since 2005 when Cardiopulmonary Resuscitation recommendations were changed from 2 ventilations to 15 compressions and up to three stacked shocks for shockable rhythms, to 30 compressions to 2 ventilations and single shocks. Since 2010, basic life support has largely focused on the importance of providing high-quality CPR for professional and lay rescuers alike. The most recent resuscitation updates has seen an increased focus on the systems perspective. The 'Systems Saving Lives' concept emphasizes the interconnection between community and Emergency Medical Services (EMS). The main changes in current resuscitation practice are within three important basic life support domains: recognition of cardiac arrest, interaction between rescuers and EMS and improving resuscitation quality.

SUMMARY

This review highlights the importance of strengthening both community and emergency medical services efforts to improve outcomes in cardiac arrest. Strategies that enhance the communication and collaboration between lay rescuers and professional resuscitation systems are important new avenues to pursue in developing systems that save more lives.

Are there disparities in the location of automated external defibrillators in England?

Background

Early defibrillation is an essential element of the chain of survival for out-of-hospital cardiac arrest (OHCA). Public access defibrillation (PAD) programmes aim to place automated external defibrillators (AED) in areas with high OHCA incidence, but there is sometimes a mismatch between AED density and OHCA incidence.

Objectives

This study aimed to assess whether there were any disparities in the characteristics of areas that have an AED and those that do not in England.

Methods

Details of the location of AEDs registered with English Ambulance Services were obtained from individual services or internet sources. Neighbourhood characteristics of lower layer super output areas (LSOA) were obtained from the Office for National Statistics. Comparisons were made between LSOAs with and without a registered AED.

Results

AEDs were statistically more likely to be in LSOAs with a lower residential but higher workplace population density, with people predominantly from a white ethnic background and working in higher socio-economically classified occupations (p < 0.05). There was a significant correlation between AED coverage and the LSOA Index of Multiple Deprivation (IMD) (r = 0.79, p = 0.007), with only 27.4% in the lowest IMD decile compared to about 45% in highest. AED density varied significantly across the country from 0.82/km² in the north east to 2.97/km² in London.

Conclusions

In England, AEDs were disproportionately placed in more affluent areas, with a lower residential population density. This contrasts with locations where OHCAs have previously occurred. Future PAD programmes should give preference to areas of higher deprivation and be tailored to the local community.

Functional outcomes following an in-hospital cardiac arrest: A retrospective cohort study

BACKGROUND/PURPOSE

Whilst much is known about the survival outcomes of patients that suffer an in-hospital cardiac arrest (IHCA) in Australia very little is known about the functional outcomes of survivors. This study aimed to describe the functional outcomes of a cohort of patients that suffered an in-hospital cardiac arrest (IHCA) and survived to hospital discharge in a regional Australian hospital.

METHODS

This is a single-centre retrospective observational cohort study conducted in a regional Australian hospital. All adult patients that had an IHCA in the study hospital between 1 Jan 2017 and 31 Dec 2019 and survived to hospital discharge were included in the study. Functional outcomes were reported using the Modified Rankin Scale (mRS), a six-point scale for which increasing scores represent increasing disability. Scores were assigned through a retrospective review of medical notes.

RESULTS

Overall, 102 adult patients had an IHCA during the study period, of whom 50 survived to hospital discharge. The median age of survivors was 68 years, and a third had a shockable initial arrest rhythm. Of survivors, 47 were able to be assigned both mRS scores. At discharge, 81% of patients achieved a favourable functional outcome (mRS 0-3 or equivalent function at discharge equal to admission).

CONCLUSIONS

Most survivors to hospital discharge following an IHCA have a favourable functional outcome and are discharged home. Although these results are promising, larger studies across multiple hospitals are required to further inform what is known about functional outcomes in Australian IHCA survivors.

Singapore Advanced Cardiac Life Support Guidelines 2021

Advanced cardiac life support (ACLS) emphasises the use of advanced airway management and ventilation, circulatory support and the appropriate use of drugs in resuscitation, as well as the identification of reversible causes of cardiac arrest. Extracorporeal cardiopulmonary resuscitation and organ donation, as well as special circumstances including drowning, pulmonary embolism and pregnancy are addressed. Resuscitation does not end with ACLS but must continue in post-resuscitation care. ACLS also covers the recognition and management of unstable pre-arrest tachy- and bradydysrhythmias that may deteriorate further.

Out-of-hospital cardiac arrest outcomes in emergency departments

BACKGROUND

The emergency department (ED) plays an important role in out-hospital-cardiac arrest (OHCA) management. However, ED outcomes are not widely reported. This study aimed to (1) describe OHCA ED outcomes and reasons for ED deaths, and (2) whether these differed between hospitals.

METHODS

Data were obtained from the Victorian Ambulance Cardiac Arrest Registry and 12 hospitals for adult, non-traumatic OHCA cases transported to ED between 2014 and 2016. Multivariable logistic regression was used to examine the association of level of cardiac arrest centre on ED survival in a subset of cases (non-paramedic witnessed OHCA who were unconscious on ED arrival with ROSC).

RESULTS

Of 1547 eligible OHCA cases, 81% (N = 1254) survived ED, varying between 57% to 88% between EDs. Among non-survivors, the majority had either: cessation of resuscitation after presenting with CPR in progress (27%); withdrawal of life-sustaining treatment for non-neurological (n = 65, 22%) or neurological (16%) reasons; or a unsuccessful resuscitation following a rearrested in ED (20%). These causes of ED deaths varied between the different levels of cardiac arrest centres, and in our subset of interest (n = 952) ED survival was associated with transportation to centres with high annual OHCA volumes and with 24-hour cardiac intervention capabilities (AOR = 3.43, 95% CI 1.89-6.21).

CONCLUSION

Our study found wide variation in survival between EDs, which was associated with hospital characteristics. Such data suggests the need for a detailed review of ED deaths, particularly in non-cardiac arrest centres, and potentially the need for monitoring ED survival as a measure of quality.

Analysis of Characteristics and Mortality in Cardiac Arrest Patients by Hospital Level: a Nationwide Population-based Study

BACKGROUND

Survival and post-cardiac arrest care vary considerably by hospital, region, and country. In the current study, we aimed to analyze mortality in patients who underwent cardiac arrest by hospital level, and to reveal differences in patient characteristics and hospital factors, including post-cardiac arrest care, hospital costs, and adherence to changes in resuscitation guidelines.

METHODS

We enrolled adult patients (≥ 20 years) who suffered non-traumatic cardiac arrest from 2006 to 2015. Patient demographics, insurance type, admission route, comorbidities, treatments, and hospital costs were extracted from the National Health Insurance Service database. We categorized patients into tertiary hospital, general hospital, and hospital groups according to the level of the hospital where they were treated. We analyzed the patients' characteristics, hospital factors, and mortalities among the three groups. We also analyzed post-cardiac arrest care before and after the 2010 guideline changes. The primary end-point was 30 days and 1 year mortality rates.

RESULTS

The tertiary hospital, general hospital, and hospital groups represented 32.6%, 49.6%, and 17.8% of 337,042 patients, respectively. The tertiary and general hospital groups were younger, had a lower proportion of medical aid coverage, and fewer comorbidities, compared to the hospital group. Post-cardiac arrest care, such as percutaneous coronary intervention, targeted temperature management, and extracorporeal membrane oxygenation, were provided more frequently in the tertiary and general hospital groups. After adjusting for age, sex, insurance type, urbanization level, admission route, comorbidities, defibrillation, resuscitation medications, angiography, and guideline changes, the tertiary and general hospital groups showed lower 1-year mortality (tertiary hospital vs. general hospital vs. hospital, adjusted odds ratios, 0.538 vs. 0.604 vs. 1; P < 0.001). After 2010 guideline changes, a marked decline in atropine use and an increase in post-cardiac arrest care were observed in the tertiary and general hospital groups.

CONCLUSION

The tertiary and general hospital groups showed lower 30 days and 1 year mortality rates than the hospital group, after adjusting for patient characteristics and hospital factors. Higher-level hospitals provided more post-cardiac arrest care, which led to high hospital costs, and showed good adherence to the guideline change after 2010.

[Adult advanced life support]

These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

[Ethics of resuscitation and end of life decisions]

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Transportation during and after cardiac arrest: who, when, how and where?

PURPOSE OF REVIEW

Out-of-hospital cardiac arrest (OHCA) is the most devastating and time-critical medical emergency. Survival after OHCA requires an integrated system of care, of which transport by emergency medical services is an integral component. The transport system serves to commence and ensure uninterrupted high-quality resuscitation in suitable patients who would benefit, terminate resuscitation in those that do not, provide critical interventions, as well as convey patients to the next appropriate venue of care. We review recent evidence surrounding contemporary issues in the transport of OHCA, relating to who, where, when and how to transport these patients.

RECENT FINDINGS

We examine the clinical and systems-related evidence behind issues including: contemporary approaches to field termination of resuscitation in patients in whom continued resuscitation and transport to hospital would be medically futile, OHCA patients and organ donation, on-scene versus intra-transport resuscitation, significance of response time, intra-transport interventions (mechanical chest compression, targeted temperature management, ECMO-facilitated cardiopulmonary resuscitation), OHCA in high-rise locations and cardiac arrest centers. We highlight gaps in current knowledge and areas of active research.

SUMMARY

There remains limited evidence to guide some decisions in transporting the OHCA patient. Evidence is urgently needed to elucidate the roles of cardiac arrest centers and ECPR in OHCA.

Does experience in prehospital post-resuscitation critical care affect outcomes? A retrospective cohort study

AIMS OF THE STUDY

Helicopter Emergency Medical Services (HEMS) often provide post-resuscitation care. Our aims were to investigate whether physicians' frequent exposure to prehospital post-resuscitation care is associated with differences in (1) medical management, (2) achieving treatment targets recommended by resuscitation guidelines, (3) survival.

METHODS

We conducted a retrospective cohort study using data from a national HEMS quality register. We included patients between January 1st, 2012 and September 9th, 2019 who received post-resuscitation care by a HEMS physician. We excluded patients <16 years old. For each patient we determined the number of post-resuscitation cases the physician had attended in the previous 12 months. Patients were divided in to three groups: low (0-5), intermediate (6-11) and high exposure (≥12 cases). Medical management and proportions within treatment targets were compared. Survival at 30-days and 1-year was analysed by multivariate logistic regression analysis, controlling for known prognostic factors.

RESULTS

2272 patients were analysed. Patients in the high exposure group had mechanical ventilation and vasoactive medications initiated more often (P < 0.001 and P = 0.008, respectively) and on-scene times were longer (P < 0.001). The target for blood pressure was achieved more often in this group (P = 0.026), but targets for oxygenation and ventilation were not. We did not see an association between survival and physicians' exposure to post-resuscitation care (odds ratio 0.96, 95% confidence interval 0.70-1.33 for low and 0.78, 0.56-1.08 for intermediate, compared to high exposure).

CONCLUSIONS

Physicians with more, frequent exposure take a more active approach to post-resuscitation care, but this does not seem to improve survival.

European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.

European Resuscitation Council Guidelines 2021: Systems saving lives

The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.

European Resuscitation Council Guidelines 2021: Adult advanced life support

These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.

European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

European Resuscitation Council Guidelines 2021: Epidemiology of cardiac arrest in Europe

In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in and out of hospital cardiac arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are presented to enable health systems to develop registries as a platform for quality improvement and to inform health system planning and responses to cardiac arrest.

Association between admission to a cardiac arrest centre and survival to hospital discharge for adults following out-of-hospital cardiac arrest: A multi-centre observational study

AIM

This study examined the association between admission to a cardiac arrest centre and survival to hospital discharge for adults following out-of-hospital cardiac arrest (OHCA).

METHODS

We undertook a multicentre retrospective observational study of patients transferred to hospital after OHCA of presumed cardiac aetiology in three ambulance services in England. We used propensity score matching to compare rates of survival to hospital discharge in patients admitted to OHCA centres (defined as either 24/7 PPCI availability or >100 OHCA admissions per year) to rates of survival of patients admitted to non-centres.

RESULTS

Between January 2017 and December 2018, 10,650 patients with OHCA were included in the analysis. After propensity score matching, admission to a hospital with 24/7 PPCI availability or a high volume centre was associated with an absolute improvement in survival to hospital discharge of 2.5% and 2.8%, respectively. The corresponding odds ratios and 95% confidence intervals were 1.69 (1.28-2.23) and 1.41 (1.14-1.75), respectively. The results were similar when missing values were imputed. In subgroup analyses, the association between admission to an OHCA centre and improved rates of survival was mainly seen in patients with OHCA due to shockable rhythms, with no or minimal potential benefit for patients with OHCA and asystole as first presenting rhythm.

CONCLUSION

Following OHCA, admission to a cardiac arrest centre is associated with a moderate improvement in survival to hospital discharge. A corresponding bypass policy would need to consider the resulting increased workload for OHCA centres.