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Boulton AJ, Abelairas-Gómez C, Olaussen A, Skrifvars MB, Greif R, Yeung J. Cardiac arrest centres for patients with non-traumatic cardiac arrest: A systematic review. Resuscitation 2024; 203:110387. [PMID: 39242018 DOI: 10.1016/j.resuscitation.2024.110387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 08/20/2024] [Accepted: 08/31/2024] [Indexed: 09/09/2024]
Abstract
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.
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Affiliation(s)
- Adam J Boulton
- Warwick Medical School, University of Warwick, Coventry, UK.
| | - Cristian Abelairas-Gómez
- Faculty of Education Sciences and CLINURSID Research Group, Universidade de Santiago de Compostela, Santiago de Compostela, Spain; Simulation and Intensive Care Unit of Santiago (SICRUS) Research Group, Health Research Institute of Santiago, University Hospital of Santiago de Compostela-CHUS, Santiago de Compostela, Spain Research Group, Spain
| | - Alexander Olaussen
- Alfred Health Emergency Service, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Paramedicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Doncaster, Victoria, Australia; National Trauma Research Institute, Melbourne, Australia
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Robert Greif
- University of Bern, Bern, Switzerland; Department of Surgical Science, University of Torino, Torino, Italy
| | - Joyce Yeung
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham UK
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Price J, Rees P, Lachowycz K, Starr Z, Pareek N, Keeble TR, Major R, Barnard EBG. Increased survival for resuscitated Utstein-comparator group patients conveyed directly to cardiac arrest centres in a large rural and suburban population in England. Resuscitation 2024; 201:110280. [PMID: 38880470 DOI: 10.1016/j.resuscitation.2024.110280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/29/2024] [Accepted: 06/11/2024] [Indexed: 06/18/2024]
Abstract
AIM The cohort of patients in which cardiac arrest centres (CAC) in rural and suburban populations confer the greatest survival benefit remains unclear. The aim of this study was to assess whether the transfer of resuscitated Utstein-comparator out-of-hospital cardiac arrest (OHCA) patients direct to a CAC was associated with improved survival to hospital discharge compared to patients conveyed to non-specialist centres. METHODS A consecutive sample of adult (≥18 years old) Utstein-comparator patients (witnessed collapse and initial shockable rhythm) were included from the East of England Ambulance Service NHS Trust Utstein resuscitation registry; 2018-2022. Logistic regression was used to compare survival to discharge in patients transported to CACs compared with patients transported to non-specialist centres. RESULTS During the study period, resuscitation was attempted in 18,276 OHCA patients. N = 2448 (13.4%) met the Utstein-comparator definition and 1151 patients were included in the final analysis; per protocol. Survival was greater for patients conveyed directly to a CAC (n = 768, 60.7%) compared to non-specialist centres (n = 383, 47.3%); adjusted OR 1.44 (95%CI 1.07-1.94),p = 0.017. Amongst the centres analysed in this study, there was significant inter-hospital variability in survival between CACs (p = 0.017). There was no association between patient volume and survival (p = 0.850). CONCLUSION Direct transport to a cardiac arrest centre was associated with a 44% increase in the odds of survival compared to conveyance to a non-specialist centre for resuscitated adult patients presenting with witnessed collapse and initial shockable OHCA rhythm.
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Affiliation(s)
- James Price
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK; Emergency and Urgent Care Research in Cambridge (EUReCa), PACE Section, Department of Medicine, Cambridge University, Cambridge, UK.
| | - Paul Rees
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK; Barts Interventional Group, Barts Heart Centre, London, UK; The Blizard Institute, Queen Mary University of London, London, UK; Academic Department of Military Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, UK
| | - Kate Lachowycz
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Zachary Starr
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Nilesh Pareek
- Department of Cardiology, King's College Hospital NHS Foundation Trust, UK; School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King's College London, UK
| | - Thomas R Keeble
- Essex Cardiothoracic Centre, MSE, Basildon, UK; MTRC, Anglia Ruskin School of Medicine, Chelmsford, UK
| | - Rob Major
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Ed B G Barnard
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK; Emergency and Urgent Care Research in Cambridge (EUReCa), PACE Section, Department of Medicine, Cambridge University, Cambridge, UK; Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, UK
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Memenga F, Sinning C. Emerging Evidence in Out-of-Hospital Cardiac Arrest-A Critical Appraisal of the Cardiac Arrest Center. J Clin Med 2024; 13:3973. [PMID: 38999537 PMCID: PMC11242151 DOI: 10.3390/jcm13133973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 06/27/2024] [Accepted: 07/05/2024] [Indexed: 07/14/2024] Open
Abstract
The morbidity and mortality of out-of-hospital cardiac arrest (OHCA) due to presumed cardiac causes have remained unwaveringly high over the last few decades. Less than 10% of patients survive until hospital discharge. Treatment of OHCA patients has traditionally relied on expert opinions. However, there is growing evidence on managing OHCA patients favorably during the prehospital phase, coronary and intensive care, and even beyond hospital discharge. To improve outcomes in OHCA, experts have proposed the establishment of cardiac arrest centers (CACs) as pivotal elements. CACs are expert facilities that pool resources and staff, provide infrastructure, treatment pathways, and networks to deliver comprehensive and guideline-recommended post-cardiac arrest care, as well as promote research. This review aims to address knowledge gaps in the 2020 consensus on CACs of major European medical associations, considering novel evidence on critical issues in both pre- and in-hospital OHCA management, such as the timing of coronary angiography and the use of extracorporeal cardiopulmonary resuscitation (eCPR). The goal is to harmonize new evidence with the concept of CACs.
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Affiliation(s)
- Felix Memenga
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany
| | - Christoph Sinning
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany
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Kishihara Y, Kashiura M, Yasuda H, Kitamura N, Nomura T, Tagami T, Yasunaga H, Aso S, Takeda M, Moriya T. Association between institutional volume of out-of-hospital cardiac arrest cases and short term outcomes. Am J Emerg Med 2024; 75:65-71. [PMID: 37922832 DOI: 10.1016/j.ajem.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/04/2023] [Accepted: 10/08/2023] [Indexed: 11/07/2023] Open
Abstract
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.
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Affiliation(s)
- Yuki Kishihara
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama 330-8503, Japan
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama 330-8503, Japan.
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama 330-8503, Japan; Department of Clinical Research Education and Training Unit, Keio University Hospital Clinical and Translational Research Center, 35 Shinanomachi, Sinzyuku-ku, Tokyo 160-0016, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu-shi, Chiba 292-0822, Japan.
| | - Tomohisa Nomura
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima-ku, Tokyo 177-8521, Japan.
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugi-cho, Nakahara-ku, Kawasaki-shi, Kanagawa 211-8533, Japan.
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
| | - Shotaro Aso
- Department of Real World Evidence, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
| | - Munekazu Takeda
- Department of Critical Care and Emergency Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinzyuku-ku, Tokyo 162-8666, Japan.
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama 330-8503, Japan.
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5
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Hansen CM, Folke F, Granger CB. Back to basics for out-of-hospital cardiac arrest. Lancet 2023; 402:1300-1301. [PMID: 37647927 DOI: 10.1016/s0140-6736(23)01560-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/24/2023] [Indexed: 09/01/2023]
Affiliation(s)
- Carolina Malta Hansen
- Division of Cardiology, Rigshospitalet, Copenhagen University, Copenhagen 2100, Denmark; Division of Cardiology, Herlev and Gentofte Hospital, Copenhagen University, Copenhagen, Denmark; Copenhagen Emergency Medical Services, Copenhagen University, Copenhagen, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark.
| | - Fredrik Folke
- Division of Cardiology, Herlev and Gentofte Hospital, Copenhagen University, Copenhagen, Denmark; Copenhagen Emergency Medical Services, Copenhagen University, Copenhagen, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Pareek N, Rees P, Quinn T, Vopelius-Feldt JV, Gallagher S, Mozid A, Johnson T, Gudde E, Simpson R, Glover G, Davies J, Curzen N, Keeble TR. British Cardiovascular Interventional Society Consensus Position Statement on Out-of-Hospital Cardiac Arrest 1: Pathway of Care. Interv Cardiol 2022; 17:e18. [PMID: 36644626 PMCID: PMC9820135 DOI: 10.15420/icr.2022.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/10/2022] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Nilesh Pareek
- King's College Hospital NHS Foundation TrustLondon, UK,School of Cardiovascular Medicine and Sciences, British Heart Failure Centre of Excellence, King's College LondonLondon, UK
| | - Paul Rees
- Barts Interventional Group, Barts Heart CentreLondon, UK,Academic Department of Military Medicine, Defence Medical ServicesLondon, UK
| | - Tom Quinn
- Emergency, Cardiovascular and Critical Care Research Group, Kingston University and St. George's, University of LondonLondon, UK
| | | | - Sean Gallagher
- Department of Cardiology, University Hospital of WalesCardiff, UK
| | - Abdul Mozid
- Leeds Teaching Hospitals NHS Foundation TrustLeeds, UK
| | - Tom Johnson
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation TrustUK
| | - Ellie Gudde
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
| | - Rupert Simpson
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
| | - Guy Glover
- Intensive Care Unit, Guy's and St Thomas' NHS Foundation TrustLondon, UK
| | - John Davies
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
| | - Nick Curzen
- Faculty of Medicine, University of SouthamptonSouthampton, UK,Cardiothoracic Care Group, University Hospital SouthamptonSouthampton, UK
| | - Thomas R Keeble
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
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Dafaalla M, Rashid M, Van Spall HGC, Mehta L, Parwani P, Sharma G, Palmer RB, Moledina S, Volgman AS, Mamas MA. Women Are Less Likely to Survive AMI Presenting With Out-of-Hospital Cardiac Arrest: A Nationwide Study. Mayo Clin Proc 2022; 97:1608-1618. [PMID: 36058575 DOI: 10.1016/j.mayocp.2022.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 05/24/2022] [Accepted: 06/06/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the impact of patient's sex on outcomes and management of acute myocardial infarction (AMI) patients presenting with out-of-hospital cardiac arrest (OHCA). PATIENTS AND METHODS We conducted a population-based retrospective cohort study in AMI patients admitted with OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) registry. We used multivariable logistic regression models to evaluate the role of sex as a predictor of clinical outcomes and treatment strategy. RESULTS Of 16,278 patients, women constituted almost one-quarter of the population (n=3710 [22.7%]). Women were older (median age 69 [IQR, 57-79] years vs 63 [IQR, 54-72] years, P<.001), experienced longer call-to-hospital-arrival time (median, 1.2 hours vs 1.1 hours; P=.008), were less likely to present with shockable rhythm (86.8% vs 91.5%, P<.001), and less likely to receive dual antiplatelet therapy (73.8% vs 78.6%, P<.001), beta blockers (64.7% vs 72.3%, P<.001), angiotensin-converting enzyme inhibitors (49.0% vs 55.3%, P<.001), coronary angiography (73.7% vs 83.3%, P<.001), and percutaneous coronary intervention (37.5% vs. 40.7%, p 0.004). After adjusting for patient characteristics and management, women had significantly higher odds of in-hospital death compared with men (odds ratio [OR], 1.3; 95% CI, 1.1 to 1.5) and lower odds of receiving coronary angiography (OR, 0.67; 95% CI, 0.59 to 0.75) and coronary artery bypass graft (OR, 0.28; 95% CI, 0.19 to 0.40). CONCLUSION Women were less likely to survive following OHCA secondary to AMI. Hospital protocols that minimize physician bias and improve women-physician communication are needed to close this gap.
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Affiliation(s)
- Mohamed Dafaalla
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, UK; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, UK; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Harriette G C Van Spall
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine and Department of Health Research, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Laxmi Mehta
- Division of Cardiology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Garima Sharma
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Saadiq Moledina
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, UK; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - Mamas A Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, UK; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK; Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA.
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Jaffar JLY, Fook-Chong S, Shahidah N, Ho AFW, Ng YY, Arulanandam S, White A, Liew LX, Asyikin N, Leong BSH, Gan HN, Mao D, Chia MYC, Cheah SO, Ong MEH. Inter-hospital trends of post-resuscitation interventions and outcomes of out-of-hospital cardiac arrest in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:341-350. [PMID: 35786754 DOI: 10.47102/annals-acadmedsg.2021498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Hospital-based resuscitation interventions, such as therapeutic temperature management (TTM), emergency percutaneous coronary intervention (PCI) and extracorporeal membrane oxygenation (ECMO) can improve outcomes in out-of-hospital cardiac arrest (OHCA). We investigated post-resuscitation interventions and hospital characteristics on OHCA outcomes across public hospitals in Singapore over a 9-year period. METHODS This was a prospective cohort study of all OHCA cases that presented to 6 hospitals in Singapore from 2010 to 2018. Data were extracted from the Pan-Asian Resuscitation Outcomes Study Clinical Research Network (PAROS CRN) registry. We excluded patients younger than 18 years or were dead on arrival at the emergency department. The outcomes were 30-day survival post-arrest, survival to admission, and neurological outcome. RESULTS The study analysed 17,735 cases. There was an increasing rate of provision of TTM, emergency PCI and ECMO (P<0.001) in hospitals, and a positive trend of survival outcomes (P<0.001). Relative to hospital F, hospitals B and C had lower provision rates of TTM (≤5.2%). ECMO rate was consistently <1% in all hospitals except hospital F. Hospitals A, B, C, E had <6.5% rates of provision of emergency PCI. Relative to hospital F, OHCA cases from hospitals A, B and C had lower odds of 30-day survival (adjusted odds ratio [aOR]<1; P<0.05 for hospitals A-C) and lower odds of good neurological outcomes (aOR<1; P<0.05 for hospitals A-C). OHCA cases from academic hospitals had higher odds ratio (OR) of 30-day survival (OR 1.3, 95% CI 1.1-1.5) than cases from hospitals without an academic status. CONCLUSION Post-resuscitation interventions for OHCA increased across all hospitals in Singapore from 2010 to 2018, correlating with survival rates. The academic status of hospitals was associated with improved survival.
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Cardiac arrest centres: what, who, when, and where? Curr Opin Crit Care 2022; 28:262-269. [PMID: 35653246 DOI: 10.1097/mcc.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Abstract
PURPOSE OF REVIEW Out-of-hospital cardiac arrest (OHCA) is a time-critical emergency in which a rapid response following the chain of survival is crucial to save life. Disparities in care can occur at each link in this pathway and hence produce health inequities. This review summarises the health inequities that exist for OHCA patients and suggests how they may be addressed. RECENT FINDINGS There is international evidence that the incidence of OHCA is increased with increasing deprivation and in ethnic minorities. These groups have lower rates of bystander CPR and bystander-initiated defibrillation, which may be due to barriers in accessing cardiopulmonary resuscitation training, provision of public access defibrillators, and language barriers with emergency call handlers. There are also disparities in the ambulance response and in-hospital care following resuscitation. These disadvantaged communities have poorer survival following OHCA. SUMMARY OHCA disproportionately affects deprived communities and ethnic minorities. These groups experience disparities in care throughout the chain of survival and this appears to translate into poorer outcomes. Addressing these inequities will require coordinated action that engages with disadvantaged communities.
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Goh AXC, Seow JC, Lai MYH, Liu N, Man Goh Y, Ong MEH, Lim SL, Ho JSY, Yeo JW, Ho AFW. Association of High-Volume Centers With Survival Outcomes Among Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. JAMA Netw Open 2022; 5:e2214639. [PMID: 35639377 PMCID: PMC9157264 DOI: 10.1001/jamanetworkopen.2022.14639] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/13/2022] [Indexed: 11/29/2022] Open
Abstract
Importance Although high volume of cases of out-of-hospital cardiac arrest (OHCA) is a key feature of cardiac arrest centers, which have proven survival benefit, the role of center volume as an independent variable associated with improved outcomes is unclear. Objective To assess the association of high-volume centers with survival and neurological outcomes in nontraumatic OHCA. Data Sources Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to October 11, 2021, for studies including adult patients with nontraumatic OHCA who were treated at high-volume vs non-high-volume centers. Study Selection Randomized clinical trials, nonrandomized studies of interventions, prospective cohort studies, and retrospective cohort studies were selected that met the following criteria: (1) adult patients with OHCA of nontraumatic etiology, (2) comparison of high-volume with low-volume centers, (3) report of a volume-outcome association, and (4) report of outcomes of interest. At least 2 authors independently reviewed each article, blinded to each other's decision. Data Extraction and Synthesis Data abstraction and quality assessment were independently conducted by 2 authors. Meta-analyses were performed for adjusted odds ratios (aORs) and crude ORs using a random-effects model. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Main Outcomes and Measures Survival and good neurological outcomes according to the Cerebral Performance Categories Scale at hospital discharge or 30 days. Results A total of 16 studies involving 82 769 patients were included. Five studies defined high volume as 40 or more cases of OHCA per year; 3 studies defined high volume as greater than 100 cases of OHCA per year. All other studies differed in definitions. Survival to discharge or 30 days improved with treatment at high-volume centers, regardless of whether aORs (1.28 [95% CI, 1.00-1.64]) or crude ORs (1.43 [95% CI, 1.09-1.87]) were pooled. There was no association between center volume and good neurological outcomes at 30 days or hospital discharge in patients with OHCA (aOR, 0.96 [95% CI, 0.77-1.20]). Conclusions and Relevance In this meta-analysis and systematic review, care at high-volume centers was associated with improved survival outcomes, even after adjustment for potential confounders, but was not associated with improved neurological outcomes for patients with nontraumatic OHCA. More studies evaluating the relative importance of center volume compared with other variables (eg, the availability of treatment modalities) associated with survival outcomes in patients with OHCA are required.
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Affiliation(s)
- Amelia Xin Chun Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jie Cong Seow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Melvin Yong Hao Lai
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nan Liu
- Center for Quantitative Medicine, Duke-NUS (National University of Singapore) Medical School, Singapore
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Yi Man Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Center, Singapore
| | - Jamie Sin Ying Ho
- Academic Foundation Programme, Royal Free London NHS (National Health Service) Foundation Trust, London, United Kingdom
| | - Jun Wei Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Prehospital and Emergency Research Center, Duke-NUS Medical School, Singapore
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12
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Yeo JW, Ng ZHC, Goh AXC, Gao JF, Liu N, Lam SWS, Chia YW, Perkins GD, Ong MEH, Ho AFW. Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 11:e023806. [PMID: 34927456 PMCID: PMC9075197 DOI: 10.1161/jaha.121.023806] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Jun Wei Yeo
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | - Zi Hui Celeste Ng
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | | | | | - Nan Liu
- Centre for Quantitative Medicine Duke-NUS Medical SchoolNational University of Singapore Singapore
| | - Shao Wei Sean Lam
- Health Services Research Centre SingHealth Duke-NUS Academic Medical Centre Singapore
| | - Yew Woon Chia
- Department of Cardiology Tan Tock Seng Hospital Singapore
| | - Gavin D Perkins
- Warwick Medical School University of Warwick Coventry United Kingdom
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine Singapore General Hospital Singapore.,Health Services & Systems Research Duke-NUS Medical School Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine Singapore General Hospital Singapore.,Pre-Hospital and Emergency Research Centre Health Services and Systems Research Duke-NUS Medical School Singapore
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13
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Yeung J. More supportive evidence for Cardiac Arrest Centres. Resuscitation 2021; 171:103-104. [PMID: 34929297 DOI: 10.1016/j.resuscitation.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/10/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Joyce Yeung
- Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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14
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Sinning C, Hassager C. Is there are need for specialised cardiac arrest networks in patients with myocardial infarction? Closing the gap of evidence. Resuscitation 2021; 170:349-351. [PMID: 34826581 DOI: 10.1016/j.resuscitation.2021.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Christoph Sinning
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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15
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Nehme Z, Stub D. Triage of post-cardiac arrest patients: To PCI or not to PCI, that is the question. Resuscitation 2021; 170:335-338. [PMID: 34822936 DOI: 10.1016/j.resuscitation.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Ziad Nehme
- Centre of Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia; Department of Paramedicine, Monash University, Frankston, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Prahran, Victoria, Australia.
| | - Dion Stub
- Centre of Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Prahran, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Alfred Hospital, Prahran, Victoria, Australia
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16
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Dafaalla M, Rashid M, Sun L, Quinn T, Timmis A, Wijeysundera H, Bagur R, Michos E, Curzen N, Mamas MA. Impact of availability of catheter laboratory facilities on management and outcomes of acute myocardial infarction presenting with out of hospital cardiac arrest. Resuscitation 2021; 170:327-334. [PMID: 34718080 DOI: 10.1016/j.resuscitation.2021.10.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES We aimed to identify whether the availability of catheter laboratory affects clinical outcomes of out-of-hospital cardiac arrest (OHCA) complicating myocardial infarction (AMI). METHODS Patients admitted with a diagnosis of AMI and OHCA from the Myocardial Ischaemia National Audit Project (MINAP) between 2010 to 2017 were stratified into three groups based on initial hospital's catheter laboratory status: hospitals without a catheter laboratory (No-catheter lab hospitals), hospitals with diagnostic catheter laboratory (Diagnostic hospitals), and hospitals with PCI facilities (PCI hospitals). We used multivariable logistic regression to evaluate factors associated with clinical outcomes. RESULTS We included 12,303 patients of which 9,798 were admitted to PCI hospitals, 1,595 to no-catheter lab hospitals, and 910 to diagnostic hospitals. Patients admitted to PCI hospitals were more frequently reviewed by a cardiologist (96%, p < 0.001) than no-catheter lab hospitals (80%) and diagnostic hospitals (74%), and more likely to receive coronary angiography (PCI hospitals (87%), diagnostic hospitals (31%), no-catheter lab hospitals (54%), p < 0.001). They also were more likely to undergo PCI (PCI hospitals (42%), diagnostic hospitals (17%), no-catheter lab hospitals (17%), p < 0.001). After adjustment, there was no significant difference in the in-hospital mortality (OR 0.76, 95% CI 0.55-1.06) or re-infarction (OR 1.28, 95% CI 0.72-2.26) in patients admitted to PCI hospitals nor in patients admitted to diagnostic hospitals (mortality (OR 1.28, 95% CI 0.72-2.26), re-infarction (OR 1.38, 95% CI 0.68-2.82)). CONCLUSION There is variation in coronary angiography use between hospitals without a catheter laboratory and PCI centres, which was not associated with better in-hospital survival.
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Affiliation(s)
- Mohamed Dafaalla
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Louise Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Tom Quinn
- Emergency, cardiovascular and critical care research group, Kingston University and St George's, University of London, London, United Kingdom
| | - Adam Timmis
- Barts and The London NHS Trust, Cardiac Directorate, London, United Kingdom
| | - Harindra Wijeysundera
- Schulich Heart Program, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Erin Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nick Curzen
- Coronary Research Group, University Hospital Southampton NHS Trust and Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom; Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA.
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17
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Boulton AJ, Yeung J. More evidence of health inequalities in cardiac arrest outcomes. Resuscitation 2021; 167:419-421. [PMID: 34389453 DOI: 10.1016/j.resuscitation.2021.07.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Adam J Boulton
- Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Joyce Yeung
- Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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18
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Kempster K, Howell S, Bernard S, Smith K, Cameron P, Finn J, Stub D, Morley P, Bray J. Out-of-hospital cardiac arrest outcomes in emergency departments. Resuscitation 2021; 166:21-30. [PMID: 34271123 DOI: 10.1016/j.resuscitation.2021.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Kalin Kempster
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; University of Melbourne, Australia
| | - Stuart Howell
- Department of Epidemiology and Preventive Medicine, Monash University, Australia
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; Ambulance Victoria, Australia; Alfred Hospital, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; Ambulance Victoria, Australia; Department of Paramedicine, Monash University, Australia
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; Alfred Hospital, Australia
| | - Judith Finn
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; Prehospital, Resuscitation & Emergency Care Research Unit, Curtin University, Australia
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; Ambulance Victoria, Australia; Alfred Hospital, Australia; Western Hospital, Australia
| | - Peter Morley
- University of Melbourne, Australia; Royal Melbourne Hospital, Australia
| | - Janet Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; Prehospital, Resuscitation & Emergency Care Research Unit, Curtin University, Australia; Prehospital, Resuscitation & Emergency Care Research Unit, Curtin University, Australia.
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19
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Smith JE, Leech C. Time matters but getting the basics right is key to survival in out-of-hospital cardiac arrest. Emerg Med J 2021; 38:569-570. [PMID: 33731421 DOI: 10.1136/emermed-2021-211415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 03/10/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Jason E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK .,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Caroline Leech
- Emergency Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
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