Care After REsuscitation: Implementation of the United Kingdom's First Dedicated Multidisciplinary Follow-Up Program for Survivors of Out-of-Hospital Cardiac Arrest

A multidisciplinary guideline-based approach to improving the sudden cardiac arrest care pathway: The Copenhagen framework

Although recommended in the European Resuscitation Council (ERC) and European Society of Intensive Care Medicine (ESICM) Guidelines, a framework for delivering post-cardiac arrest care in a systematic manner in dedicated high-volume cardiac arrest centers is lacking in the existing literature. To our knowledge, the Copenhagen Framework is the only established framework of its kind. The framework comprises management of out-of-hospital cardiac arrest (OHCA) survivors, and follow-up, and rehabilitation. The framework also incorporates research projects on cardiac arrest survivors and their close family members. The overall aim of this paper is to describe a framework made in order to bridge the gaps between international recommendations and delivering high-quality post-resuscitation clinical care, improving the continuity of care for OHCA survivors, access to post-CA rehabilitation, a seamless transition to everyday life, and ultimately patient outcomes in the future.

British Cardiovascular Intervention Society Consensus Position Statement on Out-of-hospital Cardiac Arrest 2: Post-discharge Rehabilitation

Out-of-hospital cardiac arrest (OHCA) is a major public health issue that poses significant challenges both in immediate management and long-term follow-up. Survivors of OHCA often experience a combination of complex medical, physical and psychological needs that have a significant impact on quality of life. Guidelines suggest a multi-dimensional follow-up to address both physical and non-physical domains for survivors. However, it is likely that there is substantial unwarranted variation in provision of services throughout the UK. Currently, there is no nationally agreed model for the follow-up of OHCA survivors and there is an urgent need for a set of standards and guidelines in order to ensure equal access for all. Accordingly, the British Cardiovascular Interventional Society established a multi-disciplinary working group to develop a position statement that summarises the most up-to-date evidence and provides guidance on essential and desirable services for a dedicated follow-up pathway for survivors of OHCA.

Qualitative Study of Long‐Term Cardiac Arrest Survivors’ Challenges and Recommendations for Improving Survivorship

Background

Cardiac arrest survivorship refers to the lived experience of long‐term survivors of cardiac arrest and the many postdischarge challenges they experience. We aimed to gather a nuanced understanding of these challenges and of survivors' perceptions of ways to improve the recovery process.

Methods and Results

We conducted 15 semistructured, one‐on‐one interviews with cardiac arrest survivor members of the Sudden Cardiac Arrest Foundation; the interviews were conducted by telephone and recorded and transcribed verbatim. We used thematic analysis, informed by the Framework Method, to identify underlying themes regarding cardiac arrest survivorship challenges and recommendations to improve cardiac arrest survivorship. Regarding challenges, the overarching theme was a feeling of unpreparedness to confront postarrest challenges because of lack of resources, education, and appropriate expectations for recovery. Regarding recommendations, we uncovered 3 overarching themes including systemic recommendations (eg, providing appropriate resources and expectations, educating providers about survivorship, following up with survivors, including caregivers in treatment planning), social recommendations (eg, attending peer support groups, spending time with loved ones, providing support resources for family members), and individual coping recommendations (eg, acceptance, resilience, regaining control, seeking treatment, focusing on meaning and purpose).

Conclusions

We described common challenges that survivors of cardiac arrest face, such as lacking resources, education, and appropriate expectations for recovery. Additionally, we identified promising pathways that may improve cardiac arrest survivorship at systemic, social, and individual coping levels. Future studies could use our findings as targets for interventions to support and improve survivorship.

Exploring cognitive impairment in the early stages of an out-of-hospital cardiac arrest - a consecutive case series study

Cognitive deficits are common, although often mild, in out-of-hospital cardiac arrest patients. Prevalence and severity of cognitive deficits on discharge from acute hospital, however, are not systematically assessed in clinical practice, and not frequently reported in scientific literature, potentially hindering the development of appropriate follow-up care pathways for these patients. We hereby present data from a consecutive case series of 75 out-of-hospital cardiac arrest patients discharged from our hospital over a period of 16 months; for 46 of them we were able to obtain a cognitive profile around the time of discharge from hospital, with 37 of them experiencing cognitive deficits, ranging from mild to severe. Memory, verbal fluency and cognitive flexibility were the areas more frequently impaired. The patients we were able to assess did not differ for age, cerebral performance category score and time to return of spontaneous circulation from those we were unable to assess. Cognitive deficits were not associated with duration of "no blood flow" during cardiac arrest or with age. Our results suggest that cognitive deficits in the immediate aftermath of out-of-hospital cardiac arrest are common; however, these may be missed due to lack of systematic assessment and use of poorly sensitive cognitive tests.

Effectiveness of rehabilitation interventions on the secondary consequences of surviving a cardiac arrest: a systematic review and meta-analysis

AIM

The aim of this systematic review was to assess the effectiveness of rehabilitation interventions on the secondary physical, neurological and psychological consequences of cardiac arrest (CA) for adult survivors.

METHODS

A literature search of electronic databases (MEDLINE, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica database, Psychological Information Database, Web of Science and Cochrane Central Register of Controlled trials) was conducted for randomised controlled trials (RCTs) and observational studies up to 18 April 2021. The primary outcome was health-related quality of life (HRQoL) and main secondary outcome was neurological function with additional secondary outcomes being survival, rehospitalisation, safety (serious and non-serious adverse events), psychological well-being, fatigue, exercise capacity and physical capacity. Two authors independently screened studies for eligibility, extracted data and assessed risk of bias.

RESULTS

Three RCTs and 11 observational studies were included (total 721 participants). Study duration ranged from 8 weeks to 2 years. Pooled data from two RCTs showed low-quality evidence for no effect on physical HRQoL (standardised mean difference (SMD) 0.19, (95% CI: -0.09 to 0.47)) and no effect on mental HRQoL (SMD 0.27 (95% CI: -0.01 to 0.55)).Regarding secondary outcomes, very low-quality evidence was found for improvement in neurological function associated with inpatient rehabilitation for CA survivors with acquired brain injury (SMD 0.71, (95% CI: 0.45 to 0.96)) from five observational studies. Two small observational studies found exercise-based rehabilitation interventions to be safe for CA survivors, reporting no serious or non-serious events.

CONCLUSIONS

Given the overall low quality of evidence, this review cannot determine the effectiveness of rehabilitation interventions for CA survivors on HRQoL, neurological function or other included outcomes, and recommend further high-quality studies be conducted. In the interim, existing clinical guidelines on rehabilitation provision after CA should be followed to meet the high burden of secondary consequences suffered by CA survivors.

PROSPERO REGISTRATION NUMBER

CRD42018110129.

Follow-up care after out-of-hospital cardiac arrest: A pilot study of survivors and families' experiences and recommendations

Background and objectives

Cognitive and physical difficulties are common in survivors of out-of-hospital cardiac arrest (OHCA); both survivors and close family members are also at risk of developing mood disorders. In the UK, dedicated follow-up pathways for OHCA survivors and their family are lacking. A cohort of survivors and family members were surveyed regarding their experience of post-discharge care and their recommended improvements.

Method

123 OHCA survivors and 39 family members completed questionnaires during an educational event or later online. Questions addressed both the actual follow-up offered and the perceived requirements for optimal follow-up from the patient and family perspective, including consideration of timing, professionals involved, involvement of family members and areas they felt should be covered.

Results

Outpatient follow-up was commonly arranged after OHCA (77%). This was most often conducted by a cardiologist alone (80%) but survivors suggested that other professionals should also be involved (e.g. psychologist/counsellor, 64%). Topics recommended for consideration included cardiac arrest-related issues (heart disease; cause of arrest) mental fatigue/sleep disturbance, cognitive problems, emotional problems and daily activities. Most survivors advocated an early review (<1month; 61%). Most family members reported some psychological difficulties (95%); many of them (95%) advocated a dedicated follow-up appointment for family members of survivors.

Conclusions

The majority of OHCA survivors advocated an early follow-up following hospital discharge and a holistic, multidimensional assessment of arrest sequelae. These results suggest that current OHCA follow-up often fails to address patient-centred issues and to provide access to professionals deemed important by survivors and family members.

Gaps in the Provision of Cognitive and Psychological Resources in Cardiac Arrest Survivors with Good Neurologic Recovery

We aimed to elucidate gaps in the provision of cognitive and psychological resources in cardiac arrest survivors. We conducted an online survey study between October 29, 2019, and November 15, 2019 with cardiac arrest survivors and caregiver members of the Sudden Cardiac Arrest Foundation. We queried survivors as to whether they experienced cognitive or psychological symptoms since their cardiac arrest. Next, we queried both survivors and caregivers on the provision of resources through three metrics: (1) discussions with providers about potential cognitive or psychological symptoms, (2) neurologist or psychologist appointments scheduled by providers, and (3) mental health referrals by providers. We then ran Chi-square goodness-of-fit tests to compare the proportion of survivors and caregivers who reported resource provision (observed values) to the proportion of survivors who reported experiencing cognitive and psychological symptoms, respectively (expected values). We included responses from 167 survivors and 52 caregivers. A total of 73.1% (n = 122) survivors reported experiencing cognitive symptoms and 67.1% (n = 112) psychological symptoms since their cardiac arrest. When compared to these two proportions, provision of resources was significantly lower in all three metrics: (1) fewer discussions with providers about potential for developing cognitive symptoms (31%) and psychological symptoms (26.3%), (2) fewer neurologist appointments scheduled (8.4%) and psychologist appointments scheduled (4.8%), and (3) fewer referrals to mental health (6%). Informal caregivers also reported significantly lower provision of resources in all three metrics, with the exception of discussions about developing cognitive symptoms. Our results suggest that there are discrepancies in the provision of cognitive and psychological resources in cardiac arrest survivors with good neurologic recovery. Systematic referral processes may be needed to standardize resource provision to consistently meet the pervasive cognitive and psychological needs of cardiac arrest survivors.

The economic impact of sudden cardiac arrest

BACKGROUND

There are 20,000 sudden cardiac arrests (SCAs) in Australia annually, with 90% case-fatality.

OBJECTIVE

The present study calculated both the health and economic impact of SCAs in Victoria, Australia.

METHODS

Data on all SCAs attended by Ambulance Victoria from July 2017 to June 2018 were collected regarding age, gender, and survival to hospital, discharge and 12 months. Pre-SCA employment status of all patients was modelled using age and gender-matched Australian economic data. A Markov state-transition model with a five-year horizon calculated health and economic impact in years of life lived (YLL), productivity-adjusted life years (PALYs) and gross domestic product (GDP) lost. A counterfactual Markov state-transition model assessed outcomes of an identical cohort of patients who did not experience SCA. All values were discounted by 5%.

RESULTS

In 12 months, 4637 people suffered SCAs in Victoria, of whom 1516 (32.7%) were working at the time. 695 patients (15.0%) survived to hospital, 325 (7.0%) to discharge, and 303 (6.5%) to 12 months. In five years following their SCA, the cohort lost 15,922 years of life and 2327 PALYs. Reduced productivity led to GDP losses of AUD$448 million (92.8% relative reduction). Extrapolated to the 20,000 SCAs occurring across all of Australia, total GDP losses approached AUD$2 billion.

CONCLUSION

The health and economic burden of SCAs is high, predominantly underpinned by very high mortality. Annual national losses approach AUD$2 billion (USD$1.42 billion) and are comparable to productivity losses from all cancers combined. Prioritising research and state-of-the-art care for SCA patients appears economically sound.

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

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

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

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

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

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

Brain injury after cardiac arrest: from prognostication of comatose patients to rehabilitation

More patients are surviving cardiac arrest than ever before; however, the burden now lies with estimating neurological prognoses in a large number of patients who were initially comatose, in whom the ultimate outcome is unclear. Neurologists, neurointensivists, and clinical neurophysiologists must accurately balance the concern that overly conservative prognostication could leave patients in a severely disabled state, with the possibility that inaccurately pessimistic prognostication could lead to the withdrawal of life-sustaining treatment in patients who might otherwise have a good functional outcome. Prognostic tools have improved greatly, including electrophysiological tests, neuroimaging, and chemical biomarkers. Conclusions about the prognosis should be delayed at least 72 h after arrest to allow for the clearance of sedative drugs. Cognitive impairments, emotional problems, and fatigue are common among patients who have survived cardiac arrest, and often go unrecognised despite being related to caregiver burden and a decreased participation in society. Through simple screening, these problems can be identified, and patients can be provided with adequate information and rehabilitation.

Modifiable provider-patient relationship factors and illness perceptions are associated with quality of life in survivors of cardiac arrest with good neurologic recovery

Aim

To evaluate associations between provider-patient communication, readiness for discharge, and patients' illness perceptions with post-arrest quality of life (QoL).

Methods

We distributed an online survey to survivors of cardiac arrest who were members of the Sudden Cardiac Arrest Foundation. Survivors completed the Questionnaire for the Quality of Provider-Patient Interactions (QQPPI), Readiness for Hospital Discharge Scale (RHDS), and the Brief Illness Perception Questionnaire (B-IPQ). When completing the QQPPI and RHDS, survivors were asked to think back to their hospitalization and discharge. QoL domains (physical, psychological, social) were measured via the WHO-QOL BREF. Three multiple regression models examined associations between QQPPI, RHDS, and B-IPQ scores with QoL domains, adjusted for age, sex, months since arrest, self-reported understanding of cardiac arrest and potential post-arrest symptoms at discharge, self-reported memory at discharge, and functional status as defined by the Lawton Instrumental Activities of Daily Living scale.

Results

A total of 163 survivors (mean age: 50.1 years, 50.3% women, 95.5% white, mean time since arrest: 63.9 months) provided complete survey data. More threatening illness perceptions (β: -0.45, p ​< ​0.001) and lower readiness for discharge (β: 0.21, p ​= ​0.01) were associated with worse physical QoL. More threatening illness perceptions (β: -0.47, p ​< ​0.001) was associated with worse psychological QoL. More threatening illness perceptions (β: -0.28, p ​= ​0.001) and poor provider-patient communication (β: 0.35, p ​< ​0.001) were associated with worse social QoL.

Conclusions

Modifiable provider-patient relationship factors and illness perceptions were associated with quality of life in survivors of cardiac arrest with good neurologic recovery.