Statewide Regionalization of Postarrest Care for Out-of-Hospital Cardiac Arrest: Association With Survival and Neurologic Outcome

Cardiac arrest centres for patients with non-traumatic cardiac arrest: A systematic review

INTRODUCTION

Regionalisation and organised pathways of care using specialist centre hospitals can improve outcomes for critically ill patients. Cardiac arrest centre hospitals (CAC) may optimise the delivery of post-resuscitation care. The International Liaison Committee on Resuscitation (ILCOR) has called for a review of the current evidence base.

AIM

This systematic review aimed to assess the effect of cardiac arrest centres for patients with non-traumatic cardiac arrest.

METHODS

Articles were included if they met the prospectively registered (PROSPERO) inclusion criteria. These followed the PICOST framework for ILCOR systematic reviews. A strict definition for a CAC was used, reflecting current position statements and clinical practice. MEDLINE, Embase and the Cochrane Library were searched using pre-determined criteria from inception to 31 December 2023. Risk of bias was assessed using Cochrane's Risk of Bias tool and ROBINS-I. The certainty of evidence for each outcome was assessed using the GRADE approach. Substantial heterogeneity precluded meta-analysis and a narrative synthesis with visualisation of effect estimates in forest plots was performed.

RESULTS

Sixteen studies met eligibility criteria, including data on over 145,000 patients. One was a randomised controlled trial (RCT) at low risk of bias and the remainder were observational studies, all at moderate or serious risk of bias. All studies included adults with out-of-hospital cardiac arrest. One study used initial shockable rhythm as an inclusion criterion and most studies (n = 12) included patients regardless of prehospital ROSC status. Two studies, including the RCT, excluded patients with ST elevation. Survival to hospital discharge with a favourable neurological outcome was reported by 11 studies and favoured CAC care in all observational studies, but the RCT showed no difference. Survival to 30 days with a favourable neurological outcome was reported by two observational studies and favoured CAC care in both. Survival to hospital discharge was reported by 13 observational studies and generally favoured CAC care. Survival to 30 days was reported by two studies, where the observational study favoured CAC care, but the RCT showed no difference.

CONCLUSION

This review supports a weak recommendation that adults with out-of-hospital cardiac arrest are cared for at CACs based on very low certainty of evidence. Randomised evidence has not confirmed the benefits of CACs found in observational studies, however this RCT was a single trial in a very specific setting and a population without ST elevation on post-ROSC ECG. The role of CACs in shockable and non-shockable subgroups, direct versus secondary transfer, as well as the impact of increased transport time and bypassing local hospitals remains unclear.

The ABC (Age, Bystander, and Cardiogram) score for predicting neurological outcomes of cardiac arrests without pre-hospital return of spontaneous circulation: A nationwide population-based study

Aim

We previously proposed the ABC score to predict the neurological outcomes of cardiac arrest without prehospital return of spontaneous circulation (ROSC). Using nationwide population-based data, this study aimed to validate the ABC score through various resuscitation guideline periods.

Methods

We analysed cases with cardiac arrest due to internal causes and failure to achieve prehospital ROSC in the All-Japan Utstein Registry. Patients from the 2007-2009, 2012-2014, and 2017-2019 periods were classified into the 2005, 2010, and 2015 guideline groups, respectively. Neurological outcomes were assessed using cerebral performance categories (CPCs) one month after the cardiac arrest. We defined CPC 1-2 as a favourable outcome. We evaluated the test characteristics of the ABC score, which could range from 0 to 3.

Results

Among the 162,710, 186,228, and 190,794 patients in the 2005, 2010, and 2015 guideline groups, 0.7%, 0.8%, and 0.9% of the patients had CPC 1-2, respectively. The proportions of CPC 1-2 were 2.9%, 3.6%, and 4.6% in patients with ABC scores of 2 and were 9.5%, 13.3%, and 16.8% in patients with ABC scores of 3, respectively. Among patients with ABC scores of 0, 0.2%, 0.1%, and 0.2%, all had CPC 1-2, respectively. The areas under the receiver operating characteristic curves for the ABC score were 0.798, 0.822, and 0.828, respectively.

Conclusions

The ABC score had acceptable discrimination for neurological outcomes in patients without prehospital ROSC in the three guideline periods.

Potentially Avoidable Emergency Department Transfers for Acute Pediatric Respiratory Illness

BACKGROUND

Acute pediatric respiratory illness is one of the most common reasons for emergency department (ED) transfer; however, few studies have examined predictors of potentially avoidable ED transfer (PAT) in this subpopulation. This study aimed to characterize patterns and predictors of PATs in children with acute respiratory illness.

METHODS

Cross-sectional analysis of 8,402,577 visits for patients ≤17 years from 2018 to 2019 Health Care Utilization Project State ED and Inpatient Datasets from New York, Maryland, Wisconsin, and Florida. ED transfers matched to a visit at a receiving facility with a primary diagnosis of pneumonia, croup/other upper respiratory infection (URI), bronchiolitis, or asthma were included. PAT was defined as discharge from receiving ED or within 24 hours of inpatient admission without specialized procedures, as previously described. PATs were compared with necessary transfers using a 3-level generalized linear mixed model with adjustment for patient and hospital covariates.

RESULTS

Among 4409 matched respiratory transfers, 25.5% were potentially avoidable. Most PATs originated from EDs within the third highest quartile of annual pediatric ED visits (n = 472, 42.0%). In the multivariable model, the likelihood of PAT was higher for patients with croup/other URI ((odds ratio) OR 2.72 (2.09-3.5) and if referring ED was in the highest quartile of annual pediatric ED volumes (OR 0.48 95% (confidence interval) CI 0.26-0.88).

CONCLUSIONS

Pediatric respiratory transfers with a diagnosis of croup/other URI were the most likely to be potentially avoidable. Future implementation efforts to reduce PATs should consider focusing on croup management in EDs in the lower 3 quartiles of pediatric volume.

Advances in pediatric emergency from 2023

Most children receive emergency care by general emergency physicians and not in designated children's hospitals. There are unique considerations in the care of children that differ from the care of adults. Many management principles can be extrapolated from adult studies, but the unique pathophysiology of pediatric disease requires specialized attention and management updates. This article highlights ten impactful articles from the year 2023 whose findings can improve the care of children in the Emergency Department (ED). These studies address pediatric resuscitation, traumatic arrest, septic shock, airway management, nailbed injuries, bronchiolitis, infant fever, cervical spine injuries, and cancer risk from radiation (Table 1). The findings in these articles have the potential to impact the evaluation and management of children (Table 2).

Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Clinical Practice Update on Optimal Post Cardiac Arrest and Refractory Cardiac Arrest Patient Care

Survival to hospital discharge among patients with out-of-hospital cardiac arrest (OHCA) is low and important regional differences in treatment practices and survival have been described. Since the 2017 publication of the Canadian Cardiovascular Society's position statement on OHCA care, multiple randomized controlled trials have helped to better define optimal post cardiac arrest care. This working group provides updated guidance on the timing of cardiac catheterization in patients with ST-elevation and without ST-segment elevation, on a revised temperature control strategy targeting normothermia instead of hypothermia, blood pressure, oxygenation, and ventilation parameters, and on the treatment of rhythmic and periodic electroencephalography patterns in patients with a resuscitated OHCA. In addition, prehospital trials have helped craft new expert opinions on antiarrhythmic strategies (amiodarone or lidocaine) and outline the potential role for double sequential defibrillation in patients with refractory cardiac arrest when equipment and training is available. Finally, we advocate for regionalized OHCA care systems with admissions to a hospital capable of integrating their post OHCA care with comprehensive on-site cardiovascular services and provide guidance on the potential role of extracorporeal cardiopulmonary resuscitation in patients with refractory cardiac arrest. We believe that knowledge translation through national harmonization and adoption of contemporary best practices has the potential to improve survival and functional outcomes in the OHCA population.

Statewide implementation of the cardiac arrest registry to enhance survival in Ohio

Objective

Public health surveillance is essential for improving community health. The Cardiac Arrest Registry to Enhance Survival (CARES) is a surveillance system for out-of-hospital cardiac arrest (OHCA). We describe results of the organized statewide implementation of Ohio CARES.

Methods

We performed a retrospective analysis of CARES enactment in Ohio. Key elements included: establishment of statewide leadership, appointment of a dedicated coordinator, conversion to a statewide subscription, statewide dissemination of information, fundraising from internal and external stakeholders, and conduct of resuscitation academies. We identified all adult (≥18 years) OHCA reported in the registry during 2013-2020. We evaluated OHCA characteristics before (2013-2015) and after (2016-2019) statewide implementation using chi-square test. We evaluated trends in OHCA outcomes using the Cochran-Armitage test of trend.

Results

Statewide CARES promotion increased participation from 2 (urban) to 136 (129 urban, 7 rural) EMS agencies. Covered population increased from 1.2 M (10% of state) to 4.8 M (41% of state). After statewide implementation, OHCA populations increased male (58.1% vs 60.8%, p < 0.01), white (50.1% vs 63.7%, p < 0.01), bystander witnessed (26.9% vs 32.9%, p < 0.01) OHCAs. Bystander CPR (34.7% vs 33.2%, p = 0.22), bystander AED (13.5% vs 12.3%, p = 0.55) and initial rhythm (shockable 18.0% vs 18.3%, p = 0.32) did not change. From 2013 to 2019 there were temporal increases in ROSC (29.7% to 31.9%, p-trend = 0.028), survival (7.4% to 12.3%, p-trend < 0.001) and survival with good neurologic outcome (5.6% to 8.6%, p-trend = 0.047).

Conclusion

The organized statewide implementation of CARES in Ohio was associated with marked increases in community uptake and concurrent observed improvements in patient outcomes. These results highlight key lessons for community-wide fostering of OHCA surveillance.

Cardiac Catheterization Laboratory Management of the Comatose Adult Patient With an Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association

Out-of-hospital cardiac arrest is a leading cause of death, accounting for ≈50% of all cardiovascular deaths. The prognosis of such individuals is poor, with <10% surviving to hospital discharge. Survival with a favorable neurologic outcome is highest among individuals who present with a witnessed shockable rhythm, received bystander cardiopulmonary resuscitation, achieve return of spontaneous circulation within 15 minutes of arrest, and have evidence of ST-segment elevation on initial ECG after return of spontaneous circulation. The cardiac catheterization laboratory plays an important role in the coordinated Chain of Survival for patients with out-of-hospital cardiac arrest. The catheterization laboratory can be used to provide diagnostic, therapeutic, and resuscitative support after sudden cardiac arrest from many different cardiac causes, but it has a unique importance in the treatment of cardiac arrest resulting from underlying coronary artery disease. Over the past few years, numerous trials have clarified the role of the cardiac catheterization laboratory in the management of resuscitated patients or those with ongoing cardiac arrest. This scientific statement provides an update on the contemporary approach to managing resuscitated patients or those with ongoing cardiac arrest.

Impact of age on survival for patients receiving ECPR for refractory out-of-hospital VT/VF cardiac arrest

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) has been shown to improve neurologically favorable survival for patients with refractory ventricular tachycardia (VT)/ventricular fibrillation (VF) out-of-hospital cardiac arrest. Prior studies of the impact of age on outcomes in ECPR have demonstrated mixed results and we aim to investigate this relationship.

METHODS

Patients treated with ECPR at the University of Minnesota Medical Center for refractory out-of-hospital VT/VF arrest from December 2015 to February 2023 were included. The primary endpoints included neurologically favorable survival to discharge. A receiver operating characteristic curve was used to determine an optimal predictive age limit with the highest accuracy for neurologically favorable survival.

RESULTS

391 consecutive patients were included: 22% (n = 86) were female and the mean age was 56.9 ± 11.8 years. Age was independently associated with neurologically favorable survival to discharge, with a 30% decrease in survival with every 10-year increase in age (OR 0.7 (0.57-0.87), p = 0.001. Among those with neurologically favorable survival to discharge, older patients had longer length of hospital stay compared to younger age groups (p = 0.002) while patients who failed to achieve neurologically favorable survival to discharge had similar length of stay independent of age (p = 0.51).

CONCLUSIONS

Age is associated with neurologically favorable survival to discharge for patients receiving ECPR for refractory out-of-the-hospital VT/VF cardiac arrest. However, with a survival rate of 23% in the oldest age group, caution should be used when choosing age criteria for patient selection.

Standardizing post-cardiac arrest care across rural-urban settings - qualitative findings on proposed post-cardiac arrest learning community intervention

BACKGROUND

Standardization of post-cardiac arrest care between emergency department arrival and intensive care unit admission can be challenging, particularly for rural centers, which can experience significant delays in interfacility transfer. One approach to addressing this issue is to form a post-cardiac arrest learning community (P-CALC) consisting of emergency department (ED) and intensive care unit (ICU) physicians and nurses who use data, shared resources, and collaboration to improve post-cardiac arrest care. MaineHealth, the largest regional health system in Maine, launched its P-CALC in 2022.

OBJECTIVE

To explore P-CALC participants' perspectives on current post-cardiac arrest care, attitudes toward implementing a P-CALC intervention, perceived barriers and facilitators to intervention implementation, and implementation strategies.

METHODS

We conducted semi-structured, individual, qualitative interviews with 16 staff from seven system EDs spanning the rural-urban spectrum. Directed content analysis was used to discern key themes in transcribed interviews.

RESULTS

Participants highlighted site- and system-level factors influencing current post-cardiac arrest care. They expressed both positive attitudes and concerns about the P-CALC intervention. Multiple facilitators and barriers were identified in regard to the intervention implementation. Five proposed implementation strategies emerged as important factors to move the intervention forward.

CONCLUSIONS

Implementation of a P-CALC intervention to effect system-wide improvements in post-cardiac arrest care is complex. Understanding providers' perspectives on current care practices, feasibility of quality improvement, and potential intervention impacts is essential for program development.

Comparing strategies for prehospital transport to specialty care after cardiac arrest

Outcomes are better when patients resuscitated from out-of-hospital cardiac arrest (OHCA) are treated at specialty centers. The best strategy to transport patients from the scene of resuscitation to specialty care is unknown.

METHODS

We performed a retrospective cohort study. We identified patients treated at a single specialty center after OHCA from 2010 to 2021 and used OHCA geolocations to develop a catchment area using a convex hull. Within this area, we identified short term acute care hospitals, OHCA receiving centers, adult population by census block group, and helicopter landing zones. We determined population-level times to specialty care via: (1) direct ground transport; (2) transport to the nearest hospital followed by air interfacility transfer; and (3) ground transport to air ambulance. We used an instrumental variable (IV) adjusted probit regression to estimate the causal effect of transport strategy on functionally favorable survival to hospital discharge.

RESULTS

Direct transport to specialty care by ground to air ambulance had the shortest population-level times from OHCA to specialty care (median 56 [IQR 47-66] minutes). There were 1,861 patients included in IV regression of whom 395 (21%) had functionally favorable survival. Most (n = 1,221, 66%) were transported to the nearest hospital by ground EMS then to specialty care by air. Patient outcomes did not differ across transport strategies in our IV analysis.

DISCUSSION

We did not find strong evidence in favor of a particular strategy for transport to specialty care after OHCA. Population level time to specialty care was shortest with ground ambulance transport to the nearest helicopter landing zone.

Hospital ECMO capability is associated with survival in pediatric cardiac arrest

AIM

Extracorporeal membrane oxygenation (ECMO) provides temporary support in severe cardiac or respiratory failure and can be deployed in children who suffer cardiac arrest. However, it is unknown if a hospital's ECMO capability is associated with better outcomes in cardiac arrest. We evaluated the association between pediatric cardiac arrest survival and the availability of pediatric extracorporeal membrane oxygenation (ECMO) at the treating hospital.

METHODS

We identified cardiac arrest hospitalizations, including in- and out-of-hospital, in children (0-18 years old) using data from the Health Care Utilization Project (HCUP) National Inpatient Sample (NIS) between 2016 and 2018. The primary outcome was in-hospital survival. Hierarchical logistic regression models were built to test the association between hospital ECMO capability and in-hospital survival.

RESULTS

We identified 1276 cardiac arrest hospitalizations. Survival of the cohort was 44%; 50% at ECMO-capable hospitals and 32% at non-ECMO hospitals. After adjusting for patient-level factors and hospital factors, receipt of care at an ECMO- capable hospital was associated with higher in-hospital survival, with an odds ratio of 1.49 [95% CI 1.09, 2.02]. Patients who received treatment at ECMO-capable hospitals were younger (median 3 years vs 11 years, p < 0.001) and more likely to have a complex chronic condition, specifically congenital heart disease. A total of 10.9% (88/811) of patients at ECMO-capable hospitals received ECMO support.

CONCLUSION

A hospital's ECMO capability was associated with higher in-hospital survival among children suffering cardiac arrest in this analysis of a large United States administrative dataset. Future work to understand care delivery differences and other organizational factors in pediatric cardiac arrest is necessary to improve outcomes.

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.

The Intersection Between Heart Failure and Critical Care Cardiology: An International Perspective on Structure, Staffing, and Design Considerations

The overall patient population in contemporary cardiac intensive care units (CICUs) has only increased with respect to patient acuity, complexity, and illness severity. The current population has more cardiac and noncardiac comorbidities, a higher prevalence of multiorgan injury, and consumes more critical care resources than previously. Patients with heart failure (HF) now occupy a large portion of contemporary tertiary or quaternary care CICU beds around the world. In this review, we discuss the core issues that relate to the care of critically ill patients with HF, including global perspectives on the organization, designation, and collaboration of CICUs regionally and across institutions, as well as unique models for provisioning care for patients with HF within a health care setting. The latter includes a discussion of traditional and emerging models, specialized HF units, the makeup and implementation of multidisciplinary team-based decision-making, and cardiac critical care admission and triage practices. This article illustrates the ways in which critically ill patients with HF have helped to shape contemporary CICUs throughout the world and explores how these very patients will similarly help to inform the future maturation of these specialized critical care units. Finally, we will critically examine broad, contemporary, international models of HF and cardiac critical care delivery in North America, Europe, South America, and Asia, and conclude with opportunities for the further investigation and generation of evidence for care delivery.

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.

Influence of the Type of Physician on Survival from Emergency-Medical-Service-Witnessed Cardiac Arrest: An Observational Study

Out-of-hospital cardiac arrest resuscitation by non-emergency dedicated physicians may not be positively associated with survival, as these physicians have less experience and exposure than specialised dedicated personnel. The aim of this study was to compare the survival results of the teams led by emergency dedicated physicians (EDPhy) with those of the teams led by non-emergency dedicated physicians (N-EDPhy) and with a team of basic life support (BLS) emergency technicians (EMTs) used as the control group. A retrospective, multicentre study of emergency-medical-service-witnessed cardiac arrest from medical causes in adults was performed. The records from 2006 to 2016 in a database of a regional emergency system were analysed and updated up to 31 December 2021. Two groups were studied: initial shockable and non-shockable rhythms. In total, 1359 resuscitation attempts were analysed, 281 of which belonged to the shockable group, and 1077 belonged to the non-shockable rhythm group. Any onsite return of spontaneous circulation, patients admitted to the hospital alive, global survival, and survival with a cerebral performance category (CPC) of 1-2 (good and moderate cerebral performance) were studied, with both of the latter categories considered at 30 days, 1 year (primary outcome), and 5 years. The shockable and non-shockable rhythm group (and CPC 1-2) survivals at 1 year were, respectively, as follows: EDPhy, 66.7 % (63.4%) and 14.0% (12.3%); N-EDPhy, 16.0% (16.0%) and 1.96 % (1.47%); and EMTs 32.0% (29.7%) and 1.3% (0.84%). The crude ORs were EDPhy vs. N-EDPhy, 10.50 (5.67) and 8.16 (4.63) (all p < 0.05); EDPhy vs. EMTs, 4.25 (2.65) and 12.86 (7.80) (p < 0.05); and N-EDPhy vs. EMTs, 0.50 (0.76) (p < 0.05) and 1.56 (1.32) (p > 0.05). The presence of an EDPhy was positively related to all the survival and CPC rates.

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.

Advocacy and Legislation for Regionalization Practices in the Treatment of Cardiogenic Shock: The Time Is Now

Cardiogenic shock is a complex hemodynamic state that, despite improvements in care, often remains challenging to treat and confers a high mortality rate. Timely application of advanced strategies, including advanced hemodynamic management and mechanical circulatory support, is of the utmost importance for this critically ill patient population. Based on data and historic experiences with similar life-threatening conditions, a national system in the US of regionalized, structured care for patients with cardiogenic shock has the potential to improve outcomes and save lives. To enact this, national and state leaders, as well as federal regulatory bodies, physician thought leaders, industry representatives, and national organizations, must collaborate and advocate for a clear, structured cardiac shock center network with a tiered model for delivery of care for the sickest population of cardiac patients.

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.

Time to specialty care and mortality after cardiac arrest

INTRODUCTION

Out of hospital cardiac arrest (OHCA) patients are often transported to the closest emergency department (ED) or cardiac center for initial stabilization and may be transferred for further care. We investigated the effects of delay to transfer on in hospital mortality at a receiving facility.

METHODS

We included OHCA patients transported from the ED by a single critical care transport service to a quaternary care facility between 2010 and 2018. We calculated dwell time as time from arrest to critical care transport team contact. We abstracted demographics, arrest characteristics, and interventions started prior to transport arrival. For the primary analysis, we used logistic regression to determine the association of dwell time and in-hospital mortality. As secondary outcomes we investigated for associations of dwell time and mortality within 24 h of arrival, proximate cause of death among decedents, arterial pH and lactate on arrival, sum of worst SOFA subscales within 24 h of arrival, and rearrest during interfacility transport.

RESULTS

We included 572 OHCA patients transported from an outside ED to our facility. Median dwell time was 113 (IQR = 85-159) minutes. Measured in 30 min epochs, increasing dwell time was not associated with in-hospital mortality, 24-h mortality, cause of death and initial pH, but was associated with lower 24-h SOFA score (p = 0.01) and lower initial lactate (p = 0.03). Rearrest during transport was rare (n = 29, 5%). Dwell time was associated with lower probability of rearrest during transport (OR = 0.847, (95% CI 0.68-1.01), p = 0.07).

CONCLUSIONS

Dwell time was not associated with in-hospital mortality. Rapid transport may be associated with risk of rearrest. Prospective data are needed to clarify optimal patient stabilization and transport strategies.

Hispanic/Latino-Serving Hospitals Provide Less Targeted Temperature Management Following Out-of-Hospital Cardiac Arrest

Background Variation exists in outcomes following out-of-hospital cardiac arrest, but whether racial and ethnic disparities exist in postarrest provision of targeted temperature management (TTM) is unknown. Methods and Results We performed a retrospective analysis of a prospectively collected cohort of patients who survived to admission following out-of-hospital cardiac arrest from the Cardiac Arrest Registry to Enhance Survival, whose catchment area represents ≈50% of the United States from 2013 to 2019. Our primary exposure was race or ethnicity and primary outcome was utilization of TTM. We built a mixed-effects model with both state of arrest and admitting hospital modeled as random intercepts to account for clustering. Among 96 695 patients (24.6% Black patients, 8.0% Hispanic/Latino patients, and 63.4% White patients), a smaller percentage of Hispanic/Latino patients received TTM than Black or White patients (37.5% versus 45.0% versus 43.3%, P<0.001) following out-of-hospital cardiac arrest. In the mixed-effects model, Black patients (odds ratio [OR], 1.153 [95% CI, 1.102-1.207], P<0.001) and Hispanic/Latino patients (OR, 1.086 [95% CI, 1.017-1.159], P<0.001) were slightly more likely to receive TTM compared with White patients, perhaps because of worse neurological status on admission. We did find community- level disparity because Hispanic/Latino-serving hospitals (defined as the top decile of hospitals that cared for the highest proportion of Hispanic/Latino patients) provided less TTM (OR, 0.587 [95% CI, 0.474-0.742], P<0.001). Conclusions Reassuringly, we did not find evidence of intrahospital or interpersonal racial or ethnic disparity in the provision of TTM. However, we did find interhospital, community-level disparity. Hispanic/Latino-serving hospitals provided less guideline-recommended TTM after out-of-hospital cardiac arrest.

Between-hospital variability in organ donation after resuscitation from out-of-hospital cardiac arrest

INTRODUCTION

Survival and recovery after out-of-hospital cardiac arrest (OHCA) varies between hospitals, with better outcomes associated with high-volume and specialty care. We evaluated if there is a similar relationship with organ donation after OHCA.

METHODS

We studied a cohort of adults resuscitated from OHCA from 2010 to 2018, treated at one of 112 hospitals served by a regional organ procurement organization (OPO). We obtained hospital-level characteristics from Centers for Medicare and Medicaid Services and Health Resources and Services Administration and obtained patients' clinical information from the OPO health record. We excluded patients with no potential to donate on initial referral. Our primary exposure was treatment at a high-volume hospital (defined >500 eligible cases during the study period) and our primary outcomes were suitability to donate after full medical evaluation, successful organ procurement and organ transplantation. We used mixed effects models to quantify between-hospital variability in the primary outcomes RESULTS: Overall, 9,792 patients were included and 796 (8%) were organ donors. We identified significant between-hospital variation in odds of donation (median odds ratio 1.64 [95% CI 1.42 - 2.02]). Hospital volume explained the greatest proportion of variability. High volume centers had a higher proportion of referrals with potential to donate (16.9 vs 12.2%), actual donation (10.3 vs 6.2%), and successful transplantation (9.4 vs 5.7%). Overall, 2032/7763 (26%) of recovered transplantable organs in this region were procured from OHCA patients.

CONCLUSION

High volume centers are more likely to refer and procure transplantable organs from patients with non-survivable OHCA.

Relationship between markers of inflammation and hemodynamic stress and death in patients with out-of-hospital cardiac arrest

Biomarkers that reflect hemodynamic stress, inflammation, extracellular matrix remodeling, angiogenesis, and endothelial dysfunction may improve risk stratification and add valuable pathobiological insight in patients with out-of-hospital cardiac arrest (OHCA). In total, 120 patients with OHCA who survived at least 48 h after return of spontaneous circulation were consecutively included in the present analysis. Concentrations of 30 biomarkers were measured simultaneously using a multi-panel biomarker assay. Cox regression models were adjusted for age, sex, estimated glomerular filtration rate, lactate concentration, bystander resuscitation, initial cardiac rhythm, and type of targeted temperature management. Overall, 57 patients (47.5%) had a favorable neurological outcome (Cerebral Performance Category ≤ 2) at 30 days, while palliative care was initiated in 49 patients (40.8%), and 52 patients (43.3%) died. After correction for multiple testing with Bonferroni-Holm, 8 biomarkers (including Angiopoietin-2, Procalcitonin, Resistin, IL-4Rα, MMP-8, TNFα, Renin, and IL-1α) were significantly associated with all-cause death. After multivariable adjustment, only angiopoietin-2 (Adjusted (Adj) hazard ratio (HR) per 1-unit increase in standardized biomarker concentrations 1.52 (95% CI 1.16–1.99)) and renin (Adj HR 1.32 (95% CI 1.06–1.65) remained independently associated with an increased risk of death. The discriminatory performance indicated good performance for angiopoietin-2 (area under the curve (AUC): 0.75 (95% CI 0.66–0.75) and was significantly higher (P = 0.011) as compared with renin (AUC: 0.60, 95% CI 0.50–0.60). In conclusion, angiopoietin-2 was significantly associated with all-cause mortality in patients with OHCA who survived the first 48 h and may prove to be useful for risk stratification of these patients.

Measuring Core Body Temperature Using a Non-invasive, Disposable Double-Sensor During Targeted Temperature Management in Post-cardiac Arrest Patients

Background: Precisely measuring the core body temperature during targeted temperature management after return of spontaneous circulation is mandatory, as deviations from the recommended temperature might result in side effects such as electrolyte imbalances or infections. However, previous methods are invasive and lack easy handling. A disposable, non-invasive temperature sensor using the heat flux approach (Double Sensor), was tested against the standard method: an esophagus thermometer.

Methods: The sensor was placed on the forehead of adult patients (n = 25, M/F, median age 61 years) with return of spontaneous circulation after cardiac arrest undergoing targeted temperature management. The recorded temperatures were compared to the established measurement method of an esophageal thermometer. A paired t-test was performed to examine differences between methods. A Bland-Altman-Plot and the intraclass correlation coefficient were used to assess agreement and reliability. To rule out possible influence on measurements, the patients' medication was recorded as well.

Results: Over the span of 1 year and 3 months, data from 25 patients were recorded. The t-test showed no significant difference between the two measuring methods (t = 1.47, p = 0.14, n = 1,319). Bland-Altman results showed a mean bias of 0.02°C (95% confidence interval 0.00–0.04) and 95% limits of agreement of −1.023°C and 1.066°C. The intraclass correlation coefficient was 0.94. No skin irritation or allergic reaction was observed where the sensor was placed. In six patients the bias differed noticeably from the rest of the participants, but no sex-based or ethnicity-based differences could be identified. Influences on the measurements of the Double Sensor by drugs administered could also be ruled out.

Conclusions: This study could demonstrate that measuring the core body temperature with the non-invasive, disposable sensor shows excellent reliability during targeted temperature management after survived cardiac arrest. Nonetheless, clinical research concerning the implementation of the sensor in other fields of application should be supported, as well as verifying our results by a larger patient cohort to possibly improve the limits of agreement.

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.

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 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 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.

Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital Injury Care for Children Study (EPIC4Kids)

STUDY OBJECTIVE

We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury.

METHODS

The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders.

RESULTS

There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+).

CONCLUSION

Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.

Effectiveness of hospital emergency department regionalization and categorization policy on appropriate patient emergency care use: a nationwide observational study in Taiwan

BACKGROUND

Emergency department (ED) overcrowding is a health services issue worldwide. Modern health policy emphasizes appropriate health services utilization. However, the relationship between accessibility, capability, and appropriateness of ED use is unknown. Thus, this study aimed to examine the effect of hospital ED regionalization policy and categorization of hospital emergency capability policy (categorization policy) on patient-appropriate ED use.

METHODS

Taiwan implemented a nationwide three-tiered hospital ED regionalization and categorization of hospital emergency capability policies in 2007 and 2009, respectively. We conducted a retrospective observational study on the effect of emergency care policy intervention on patient visit. Between 2005 and 2011, the Taiwan National Health Insurance Research Database recorded 1,835,860 ED visits from 1 million random samples. ED visits were categorized using the Yang-Ming modified New York University-ED algorithm. A time series analysis was performed to examine the change in appropriate ED use rate after policy implementation.

RESULTS

From 2005 to 2011, total ED visits increased by 10.7%. After policy implementation, the average appropriate ED visit rate was 66.9%. The intervention had no significant effect on the trend of appropriate ED visit rate.

CONCLUSIONS

Although regionalization and categorization policies did increase emergency care accessibility, it had no significant effect on patient-appropriate ED use. Further research is required to improve data-driven policymaking.

Implementation of Targeted Temperature Management After Out-of-Hospital Cardiac Arrest: Observations From the Los Angeles County Regional System

Background

Despite the benefits of targeted temperature management (TTM) for out‐of‐hospital cardiac arrest), implementation within the United States remains low. The objective of this study was to evaluate the prevalence and factors associated with TTM use in a large, urban‐suburban regional system of care.

Methods and Results

This was a retrospective analysis from the Los Angeles County regional cardiac system of care serving a population of >10 million residents. All adult patients aged ≥18 years with non‐traumatic out‐of‐hospital cardiac arrest transported to a cardiac arrest center from April 2011 to August 2017 were included. Patients awake and alert in the emergency department and patients who died in the emergency department before consideration for TTM were excluded. The primary outcome measure was prevalence of TTM use. The secondary analysis were annual trends in TTM use over the study period and factors associated with TTM use. The study population included 8072 patients; 4154 patients (51.5%) received TTM and 3767 patients (46.7%) did not receive TTM. Median age was 67 years, 4780 patients (59.2%) were men, 4645 patients (57.5%) were non‐White, and the most common arrest location was personal residence in 4841 patients (60.0%). In the adjusted analysis, younger age, male sex, an initial shockable rhythm, witnessed arrest, and receiving coronary angiography were associated with receiving TTM.

Conclusions

Within this regional system of care, use of TTM was higher than previously reported in the literature at just over 50%. Use of integrated systems of care may be a novel method to increase TTM use within the United States.

Implementation of a National 5-Year Plan for Prehospital Emergency Care in Singapore and Impact on Out-of-Hospital Cardiac Arrest Outcomes From 2011 to 2016

Background

Outcomes of patients from out‐of‐hospital cardiac arrest (OHCA) vary widely globally because of differences in prehospital systems of emergency care. National efforts had gone into improving OHCA outcomes in Singapore in recent years including community and prehospital initiatives. We aimed to document the impact of implementation of a national 5‐year Plan for prehospital emergency care in Singapore on OHCA outcomes from 2011 to 2016.

Methods and Results

Prospective, population‐based data of OHCA brought to Emergency Departments were obtained from the Pan‐Asian Resuscitation Outcomes Study cohort. The primary outcome was Utstein (bystander witnessed, shockable rhythm) survival‐to‐discharge or 30‐day postarrest. Mid‐year population estimates were used to calculate age‐standardized incidence. Multivariable logistic regression was performed to identify prehospital characteristics associated with survival‐to‐discharge across time. A total of 11 465 cases qualified for analysis. Age‐standardized incidence increased from 26.1 per 100 000 in 2011 to 39.2 per 100 000 in 2016. From 2011 to 2016, Utstein survival rates nearly doubled from 11.6% to 23.1% (P=0.006). Overall survival rates improved from 3.6% to 6.5% (P<0.001). Bystander cardiopulmonary resuscitation rates more than doubled from 21.9% to 56.3% and bystander automated external defibrillation rates also increased from 1.8% to 4.6%. Age ≤65 years, nonresidential location, witnessed arrest, shockable rhythm, bystander automated external defibrillation, and year 2016 were independently associated with improved survival.

Conclusions

Implementation of a national prehospital strategy doubled OHCA survival in Singapore from 2011 to 2016, along with corresponding increases in bystander cardiopulmonary resuscitation and bystander automated external defibrillation. This can be an implementation model for other systems trying to improve OHCA outcomes.

Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.

Early risk stratification after resuscitation from cardiac arrest

Emergency clinicians often resuscitate cardiac arrest patients, and after acute resuscitation, clinicians face multiple decisions regarding disposition. Recent evidence suggests that out-of-hospital cardiac arrest patients with return of spontaneous circulation have higher odds of survival to hospital discharge, long-term survival, and improved functional outcomes when treated at centers that can provide advanced multidisciplinary care. For community clinicians, a high volume cardiac arrest center may be hours away. While current guidelines recommend against neurological prognostication in the first hours or days after return of spontaneous circulation, there are early findings suggestive of irrecoverable brain injury in which the patient would receive no benefit from transfer. In this Concepts article, we describe a simplified approach to quickly evaluate neurological status in cardiac arrest patients and identify findings concerning for irrecoverable brain injury. Characteristics of the arrest and resuscitation, initial neurological assessment, and brain computed tomography together can identify patients with high likelihood of irrecoverable anoxic injury. Patients who may benefit from centers with access to continuous electroencephalography are discussed. This approach can be used to identify patients who may benefit from rapid transfer to cardiac arrest centers versus those who may benefit from care close to home. Risk stratification also can provide realistic expectations for recovery to families.

Inter-Hospital Transfer after Return of Spontaneous Circulation Shows no Correlation with Neurological Outcomes in Cardiac Arrest Patients Undergoing Targeted Temperature Management in Cardiac Arrest Centers

This study evaluated whether inter-hospital transfer (IHT) after the return of spontaneous circulation (ROSC) was associated with poor neurological outcomes after 6 months in post-cardiac-arrest patients treated with targeted temperature management (TTM). We used data from the Korean Hypothermia Network prospective registry from November 2015 to December 2018. These out-of-hospital cardiac arrest (OHCA) patients had either received post-cardiac arrest syndrome (PCAS) care at the same hospital or had been transferred from another hospital after ROSC. The primary endpoint was the neurological outcome 6 months after cardiac arrest. Subgroup analyses were performed to determine differences in the time from ROSC to TTM induction according to the electrocardiography results after ROSC. We enrolled 1326 patients. There were no significant differences in neurological outcomes between the direct visit and IHT groups. In patients without ST elevation, the mean time to TTM was significantly shorter in the direct visit group than in the IHT group. IHT after achieving ROSC was not associated with neurologic outcomes after 6 months in post-OHCA patients treated with TTM, even though TTM induction was delayed in transferred patients.

Relationship Between Institutional Volume of Out-of-Hospital Cardiac Arrest Cases and 1-Month Neurologic Outcomes: A Post Hoc Analysis of a Prospective Observational Study

BACKGROUND

The influence of institutional volume of out-of-hospital cardiac arrest (OHCA) cases on outcomes remains unclear.

OBJECTIVES

This study evaluated the relationship between institutional volume of adult, nontraumatic OHCA cases and 1-month favorable neurologic outcomes.

METHODS

This study retrospectively analyzed data between January 2012 and March 2013 from a prospective observational study in the Kanto area of Japan. We analyzed adult patients with nontraumatic OHCA who underwent cardiopulmonary resuscitation by emergency medical service personnel and in whom spontaneous circulation was restored. Based on the institutional volume of OHCA cases, we divided institutions into low-, middle-, or high-volume groups. The primary and secondary outcomes were 1-month favorable neurologic outcomes and 1-month survival, respectively. A multivariate logistic regression analysis adjusted for propensity score and in-hospital variables was performed.

RESULTS

Of 2699 eligible patients, 889, 898, and 912 patients were transported to low-volume (40 institutions), middle-volume (14 institutions), and high-volume (9 institutions) centers, respectively. Using low-volume centers as the reference, transport to a middle- or high-volume center was not significantly associated with a favorable 1-month neurologic outcome (adjusted odds ratio [OR] 1.21 [95% confidence interval {CI} 0.84-1.75] and adjusted OR 0.77 [95% CI 0.53-1.12], respectively) or 1-month survival (adjusted OR 1.10 [95% CI 0.82-1.47] and adjusted OR 0.76 [95% CI 0.56-1.02], respectively).

CONCLUSIONS

Institutional volume was not significantly associated with favorable 1-month neurologic outcomes or 1-month survival in OHCA. Further investigation is needed to determine the association between hospital characteristics and outcomes in patients with OHCA.

Impact of Structured Pathways for Postcardiac Arrest Care: A Systematic Review and Meta-Analysis

OBJECTIVES

Recent research has demonstrated value in selected therapeutic and prognostic interventions delivered to patients following cardiac arrest. The aim of this work was to determine if the implementation of a structured care pathway, which combines different interventions, could improve outcomes in survivors of cardiac arrest.

DATA SOURCES

PubMed and review of citations in retrieved articles.

STUDY SELECTION

Randomized trials and prospective observational studies conducted in adult cardiac arrest patients, which evaluated the impact on outcome of a structured care pathway, defined as an organized set of interventions designed specifically for postcardiac arrest patients.

DATA EXTRACTION

Data collected included study characteristics and methodologic quality, populations enrolled, interventions that were part of the cardiac arrest structured care pathway, and outcomes. The principal outcome was favorable functional status defined as a Cerebral Performance Category score of 1-2 at or after hospital discharge.

DATA SYNTHESIS

The systematic search retrieved 481 articles of which nine (total, 1,994 patients) were selected for systematic review, and six (1,422 patients) met criteria for meta-analysis. Interventions in the care pathways included early coronary angiography with or without percutaneous coronary intervention (eight studies), targeted temperature management (nine studies), and protocolized management in the ICU (seven studies). Neurologic prognostication was not a part of any of the structured pathways. Meta-analysis found significantly higher odds of achieving a favorable functional outcome in patients who were treated in a structured care pathway, when compared with standard care (odds ratio, 2.35; 95% CI, 1.46-3.81).

CONCLUSIONS

Following cardiac arrest, patients treated in a structured care pathway may have a substantially higher likelihood of favorable functional outcome than those who receive standard care. These findings suggest benefit of a highly organized approach to postcardiac arrest care, in which a cluster of evidence-based interventions are delivered by a specialized interdisciplinary team. Given the overall low certainty of evidence, definitive recommendations will need confirmation in additional high-quality studies.

Key components of a community response to out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death worldwide, with substantial geographical, ethnic and socioeconomic disparities in outcome. Successful resuscitation efforts depend on the 'chain of survival', which includes immediate recognition of cardiac arrest and activation of the emergency response system, early bystander cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions, rapid defibrillation, basic and advanced emergency medical services and integrated post-cardiac arrest care. Well-orchestrated telecommunicator CPR programmes can improve rates of bystander CPR - a critical link in the chain of survival. High-performance CPR by emergency medical service providers includes minimizing interruptions in chest compressions and ensuring adequate depth of compressions. Developing local, regional and statewide systems with dedicated high-performing cardiac resuscitation centres for post-resuscitation care can substantially improve survival after OHCA. Innovative digital tools for recognizing cardiac arrest where and when it occurs, notifying potential citizen rescuers and providing automated external defibrillators at the scene hold the promise of improving survival after OHCA. Improved implementation of the chain of survival can save thousands of lives each year.