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Bosson N, Kazan C, Sanko S, Abramson T, Eckstein M, Eisner D, Geiderman J, Ghurabi W, Gudzenko V, Mehra A, Torbati S, Uner A, Gausche-Hill M, Shavelle D. Implementation of a regional extracorporeal membrane oxygenation program for refractory ventricular fibrillation out-of-hospital cardiac arrest. Resuscitation 2023; 187:109711. [PMID: 36720300 DOI: 10.1016/j.resuscitation.2023.109711] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/07/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND eCPR, the modality of extracorporeal membrane oxygenation (ECMO) applied in the setting of cardiac arrest, has emerged as a novel therapy which may improve outcomes in select patients with out-of-hospital cardiac arrest (OHCA). To date, implementation has been mainly limited to single academic centres. Our objective is to describe the feasibility and challenges with implementation of a regional protocol for eCPR. METHODS The Los Angeles County Emergency Medical Services (EMS) Agency implemented a regional eCPR protocol in July 2020, which included coordination across multiple EMS provider agencies and hospitals to route patients with refractory ventricular fibrillation (rVF) OHCA to eCPR-capable centres (ECCs). Data were entered on consecutive patients with rVF with suspected cardiac aetiology into a centralized database including time intervals, field and in-hospital care, survival and neurologic outcome. RESULTS From July 27, 2020 through July 31, 2022, 35 patients (median age 57 years, 6 (17%) female) were routed to ECCs, of whom 11 (31%) received eCPR and 3 (27%) treated with eCPR survived, all of whom had a full neurologic recovery. Challenges encountered during implementation included cost to EMS provider agencies for training, implementation, and purchase of automatic chest compression devices, maintenance of system awareness, hospital administrative support for staffing and equipment for the ECMO program, and interdepartmental coordination at ECCs. CONCLUSION We describe the successful implementation of a regional eCPR program with ongoing patient enrolment and data collection. These preliminary findings can serve as a model for other EMS systems who seek to implement regional eCPR programs.
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Affiliation(s)
- Nichole Bosson
- Los Angeles County EMS Agency, 10100 Pioneer Blvd, Santa Fe Springs, CA 90670, USA; Harbor-UCLA Medical Center Department of Emergency Medicine and the Lundquist Institute for Research, 1000 W Carson Street, Torrance, CA 90502, USA; David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA.
| | - Clayton Kazan
- Los Angeles County Fire Department, 1320 N. Eastern Avenue, Los Angeles, CA 90063, USA
| | - Stephen Sanko
- Los Angeles County-USC Medical Center, Department of Emergency Medicine, 2051 Marengo Street, Los Angeles, CA 90033, USA; University of Southern California, Keck School of Medicine, 1975 Zonal Ave, Los Angeles, CA 90033, USA; Los Angeles Fire Department, 200 N Main Street, Los Angeles, CA 90012, USA
| | - Tiffany Abramson
- Los Angeles County-USC Medical Center, Department of Emergency Medicine, 2051 Marengo Street, Los Angeles, CA 90033, USA; University of Southern California, Keck School of Medicine, 1975 Zonal Ave, Los Angeles, CA 90033, USA
| | - Marc Eckstein
- Los Angeles County-USC Medical Center, Department of Emergency Medicine, 2051 Marengo Street, Los Angeles, CA 90033, USA; University of Southern California, Keck School of Medicine, 1975 Zonal Ave, Los Angeles, CA 90033, USA
| | - David Eisner
- Culver City Fire Department, 9770 Culver Blvd, Culver City, CA 90232, USA
| | - Joel Geiderman
- Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA; Beverly Hills Fire Department, 445 N Rexford Dr., Beverly Hills, CA 90210, USA
| | - Walid Ghurabi
- David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA; Santa Monica Fire Department, 333 Olympic Blvd, Santa Monica, CA 90401, USA
| | - Vadim Gudzenko
- David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA; Ronald Reagan UCLA Medical Center, Department of Emergency Medicine, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Anil Mehra
- Los Angeles County-USC Medical Center, Department of Emergency Medicine, 2051 Marengo Street, Los Angeles, CA 90033, USA; University of Southern California, Keck School of Medicine, 1975 Zonal Ave, Los Angeles, CA 90033, USA
| | - Sam Torbati
- Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Atilla Uner
- David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA; Ronald Reagan UCLA Medical Center, Department of Emergency Medicine, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Marianne Gausche-Hill
- Los Angeles County EMS Agency, 10100 Pioneer Blvd, Santa Fe Springs, CA 90670, USA; Harbor-UCLA Medical Center Department of Emergency Medicine and the Lundquist Institute for Research, 1000 W Carson Street, Torrance, CA 90502, USA; David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - David Shavelle
- MemorialCare Heart and Vascular Institute (MHVI), Long Beach Medical Center, 2801 Atlantic Ave, Long Beach, CA 90807, USA
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Abramson TM, Bosson N, Whitfield D, Gausche-Hill M, Niemann JT. Elevated prehospital point-of-care glucose is associated with worse neurologic outcome after out-of-hospital cardiac arrest. Resusc Plus 2022; 9:100204. [PMID: 35141573 PMCID: PMC8814821 DOI: 10.1016/j.resplu.2022.100204] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/16/2021] [Accepted: 01/08/2022] [Indexed: 11/29/2022] Open
Abstract
Objectives Hyperglycemia is associated with poor outcomes in critically-ill patients. This has implications for prognostication of patients with out-of-hospital cardiac arrest (OHCA) and for post-resuscitation care. We assessed the association of hyperglycemia, on field point-of-care (POC) testing, with survival and neurologic outcome in patients with return of spontaneous circulation (ROSC) after OHCA. Methods This was a retrospective analysis of data in a regional cardiac care system from April 2011 through December 2017 of adult patients with OHCA and ROSC who had a field POC glucose. Patients were excluded if they were hypoglycemic (glucose <60 mg/dl) or received empiric dextrose. We compared hyperglycemic (glucose >250 mg/dL) with euglycemic (glucose 60–250 mg/dL) patients. Primary outcome was survival to hospital discharge (SHD). Secondary outcome was survival with good neurologic outcome (cerebral performance category 1 or 2 at discharge). We determined the adjusted odds ratios (AORs) for SHD and survival with good neurologic outcome. Results Of 9008 patients with OHCA and ROSC, 6995 patients were included; 1941 (28%) were hyperglycemic and 5054 (72%) were euglycemic. Hyperglycemic patients were more likely to be female, of non-White race, and have an initial non-shockable rhythm compared to euglycemic patients (p < 0.0001 for all). Hyperglycemic patients were less likely to have SHD compared to euglycemic survivors, 24.4% vs 32.9%, risk difference (RD) −8.5% (95 %CI −10.8%, −6.2%), p < 0.0001. Hyperglycemic survivors were also less likely to have good neurologic outcome compared to euglycemic survivors, 57.0% vs 64.6%, RD −7.6% (95 %CI −12.9%, −2.4%), p = 0.004. The AOR for SHD was 0.72 (95 %CI 0.62, 0.85), p < 0.0001 and for good neurologic outcome, 0.70 (95 %CI 0.57, 0.86), p = 0.0005. Conclusion In patients with OHCA, hyperglycemia on field POC glucose was associated with lower survival and worse neurologic outcome.
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Abramson TM, Bosson N, Loza-Gomez A, Eckstein M, Gausche-Hill M. Utility of Glucose Testing and Treatment of Hypoglycemia in Patients with Out-of-Hospital Cardiac Arrest. PREHOSP EMERG CARE 2021; 26:173-178. [PMID: 33400602 DOI: 10.1080/10903127.2020.1869873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective: Many emergency medical services (EMS) protocols for out-of-hospital cardiac arrests (OHCA) include point-of-care (POC) glucose measurement and administration of dextrose, despite limited knowledge of benefit. The objective of this study was to describe the incidence of hypoglycemia and dextrose administration by EMS in OHCA and subsequent patient outcomes.Methods: This was a retrospective analysis of OHCA in a large, regional EMS system from 2011 to 2017. Patients ≥18 years old with non-traumatic OHCA and attempted field resuscitation by paramedics were included. The primary outcomes were frequency of POC glucose measurement, hypoglycemia (glucose <60 mg/dl), and dextrose/glucagon administration (treatment group). The secondary outcomes included field return of spontaneous circulation (ROSC), survival to hospital discharge (SHD), and survival with good neurologic outcome.Results: There were 46,211 OHCAs during the study period of which 33,851 (73%) had a POC glucose test performed. Glucose levels were documented in 32,780 (97%), of whom 2,335 (7%) were hypoglycemic. Among hypoglycemic patients, 41% (959) received dextrose and/or glucagon. Field ROSC was achieved in 30% (286) of hypoglycemic patients who received treatment. Final outcome was determined for 1,714 (73%) of the hypoglycemic cases, of whom 120 (7%) had SHD and 66 (55%) had a good neurologic outcome. Of the 32,780 patients with a documented POC glucose result who were identified as hypoglycemic, only 27 (0.08%) received field treatment, and survived to discharge with good neurologic outcome. 48 (6%) of patients in the treatment group had SHD vs. 72 (8%) without treatment, risk difference -2.0% (95%CI -4.4%, 0.4%), p = 0.1.Conclusion: In this EMS system, POC glucose testing was common in adult OHCA, yet survival to hospital discharge with good neurologic outcome did not differ between patients treated and untreated for hypoglycemia. These results question the common practice of measuring and treating hypoglycemia in OHCA patients.
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Hermel M, Bosson N, Fang A, French WJ, Niemann JT, Sung G, Thomas JL, Shavelle DM. Implementation of Targeted Temperature Management After Out-of-Hospital Cardiac Arrest: Observations From the Los Angeles County Regional System. J Am Heart Assoc 2020; 9:e016652. [PMID: 33317367 PMCID: PMC7955369 DOI: 10.1161/jaha.120.016652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Melody Hermel
- Division of Cardiology University of Southern California Los Angeles CA
| | - Nichole Bosson
- Los Angeles County Emergency Medical Service Agency Santa Fe Springs CA.,Department of Emergency Medicine Harbor UCLA Medical Center Torrance CA
| | - Andrea Fang
- Department of Emergency Medicine Stanford University Stanford CA
| | | | - James T Niemann
- Department of Emergency Medicine Harbor UCLA Medical Center Torrance CA
| | - Gene Sung
- Department of Neurology University of Southern California Los Angeles CA
| | - Joseph L Thomas
- Division of Cardiology Harbor UCLA Medical Center Torrance CA
| | - David M Shavelle
- Division of Cardiology University of Southern California Los Angeles CA
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Coppler PJ, Callaway CW, Guyette FX, Baldwin M, Elmer J. Early risk stratification after resuscitation from cardiac arrest. J Am Coll Emerg Physicians Open 2020; 1:922-931. [PMID: 33145541 PMCID: PMC7593432 DOI: 10.1002/emp2.12043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/12/2020] [Accepted: 02/18/2020] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Patrick J. Coppler
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Clifton W. Callaway
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Francis X. Guyette
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Maria Baldwin
- Department of NeurologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Jonathan Elmer
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
- Department of NeurologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
- Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
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Menon V. Targeting Mean Arterial Pressure to Limit Myocardial Injury: Novel Finding or Wild Goose Chase? J Am Coll Cardiol 2020; 76:825-827. [PMID: 32792080 DOI: 10.1016/j.jacc.2020.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Venu Menon
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
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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. J Clin Med 2020; 9:jcm9061979. [PMID: 32599840 PMCID: PMC7356325 DOI: 10.3390/jcm9061979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 11/17/2022] Open
Abstract
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.
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Berg DD, Bobrow BJ, Berg RA. Key components of a community response to out-of-hospital cardiac arrest. Nat Rev Cardiol 2020; 16:407-416. [PMID: 30858511 DOI: 10.1038/s41569-019-0175-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- David D Berg
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bentley J Bobrow
- Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Streitberger KJ, Endisch C, Ploner CJ, Stevens R, Scheel M, Kenda M, Storm C, Leithner C. Timing of brain computed tomography and accuracy of outcome prediction after cardiac arrest. Resuscitation 2019; 145:8-14. [PMID: 31585185 DOI: 10.1016/j.resuscitation.2019.09.025] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/22/2019] [Accepted: 09/15/2019] [Indexed: 11/16/2022]
Abstract
AIM Gray-white-matter ratio (GWR) calculated from head CT is a radiologic index of tissue changes associated with hypoxic-ischemic encephalopathy after cardiac arrest (CA). Evidence from previous studies indicates high specificity for poor outcome prediction at GWR thresholds of 1.10-1.20. We aimed to determine the relationship between accuracy of neurologic prognostication by GWR and timing of CT. METHODS We included 195 patients admitted to the ICU following CA. GWR was calculated from CT radiologic densities in 16 regions of interest. Outcome was determined upon intensive care unit discharge using the cerebral performance category (CPC). Accuracy of outcome prediction of GWR was compared for 3 epochs (<6, 6-24, and >24 h after CA). RESULTS 125 (64%) patients had poor (CPC4-5) and 70 (36%) good outcome (CPC1-3). Irrespective of timing, specificity for poor outcome prediction was 100% at a GWR threshold of 1.10. Among 50 patients with both early and late CT, GWR decreased significantly over time (p = 0.002) in patients with poor outcome, sensitivity for poor outcome prediction was 12% (7-20%) with early CTs (<6 h) and 48% (38-58%) for late CTs (>24 h). Across all patients, sensitivity of early and late CT was 17% (9-28%) and 39% (28-51%), respectively. CONCLUSION A GWR below 1.10 predicts poor outcome (CPC4-5) in patients after CA with high specificity irrespective of time of acquisition of CT. Because GWR decreases over time in patients with severe HIE, sensitivity for prediction of poor outcome is higher for late CTs (>24 h after CA) as compared to early CTs (<6 h after CA).
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Affiliation(s)
- Kaspar Josche Streitberger
- Department of Neurology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Christian Endisch
- Department of Neurology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Christoph J Ploner
- Department of Neurology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Robert Stevens
- Department of Anesthesiology and Critical Care Medicine and Department of Neurology, Johns Hopkins Medicine Baltimore, MA, USA
| | - Michael Scheel
- Department of Neuroradiology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Martin Kenda
- Department of Neurology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Christian Storm
- Department of Anesthesiology and Critical Care Medicine and Department of Neurology, Johns Hopkins Medicine Baltimore, MA, USA; Department of Nephrology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Christoph Leithner
- Department of Neurology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Del Rios M, Weber J, Pugach O, Nguyen H, Campbell T, Islam S, Stein Spencer L, Markul E, Bunney EB, Vanden Hoek T. Large urban center improves out-of-hospital cardiac arrest survival. Resuscitation 2019; 139:234-240. [DOI: 10.1016/j.resuscitation.2019.04.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/02/2019] [Accepted: 04/10/2019] [Indexed: 11/28/2022]
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Kaneda K, Yagi T, Todani M, Nakahara T, Fujita M, Kawamura Y, Oda Y, Tsuruta R. Impact of type of emergency department on the outcome of out-of-hospital cardiac arrest: a prospective cohort study. Acute Med Surg 2019; 6:371-378. [PMID: 31592321 PMCID: PMC6773652 DOI: 10.1002/ams2.423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 04/02/2019] [Indexed: 11/16/2022] Open
Abstract
Aim To assess whether the outcomes of out‐of‐hospital cardiac arrest (OHCA) differ between patients treated at tertiary or secondary emergency medical facilities. Methods Data from the Japanese Association for Acute Medicine Out‐of‐Hospital Cardiac Arrest (JAAM‐OHCA) registry between June 2014 and December 2015 were analyzed and compared between patients treated at tertiary (tertiary group) and secondary (secondary group) emergency medical facilities. The primary outcome of this study was a favorable neurological outcome at 1 and 3 months after OHCA, defined as a Glasgow–Pittsburgh cerebral performance category of 1 or 2. Results Between June 2014 and December 2015, a total of 13,491 patients with OHCA were registered in the JAAM‐OHCA registry. Of these, 12,836 were eligible in the present analysis, with 11,583 in the tertiary group and 1,253 in the secondary group. The proportions of patients with favorable neurological outcomes in the tertiary group were significantly higher than those in the secondary group at 1 (4.7% versus 2.0%, P < 0.001) and 3 (3.5% versus 1.6%, P < 0.001) months after OHCA. Even after adjusting for baseline characteristics of patients, treatment at a tertiary emergency medical facility was independently associated with favorable neurological outcomes at 1 (odds ratio, 2.856, 95% confidence interval, 1.429–5.710; P = 0.003) and 3 (odds ratio, 2.462, 95% confidence interval, 1.203–5.042; P = 0.014) months after OHCA. Conclusion The neurological outcomes of patients with OHCA treated at tertiary emergency medical facilities were better than those of patients treated at secondary emergency medical facilities.
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Affiliation(s)
- Kotaro Kaneda
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
| | - Takeshi Yagi
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
| | - Masaki Todani
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
| | - Takashi Nakahara
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
| | - Motoki Fujita
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
| | - Yoshikatsu Kawamura
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
| | - Yasutaka Oda
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
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Bosson N, Fang A, Kaji AH, Gausche-Hill M, French WJ, Shavelle D, Thomas JL, Niemann JT. Racial and ethnic differences in outcomes after out-of-hospital cardiac arrest: Hispanics and Blacks may fare worse than non-Hispanic Whites. Resuscitation 2019; 137:29-34. [DOI: 10.1016/j.resuscitation.2019.01.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/29/2019] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
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Outcomes of in-hospital treatment of cardiac patients who survived cardiac arrest and experienced coronary angiography. ACTA ACUST UNITED AC 2019; 3:e1-e7. [PMID: 30775583 PMCID: PMC6374574 DOI: 10.5114/amsad.2018.73212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/15/2018] [Indexed: 11/17/2022]
Abstract
Introduction As coronary artery disease is the most frequent cause of cardiac arrest, early invasive strategies may be beneficial for such patients. This study analyses the impact of in-hospital treatment on short-term outcomes of out-of-hospital cardiac arrest (OHCA) survivors. Material and methods Patients admitted to the Cardiac Intensive Care Unit of our hospital within 2-year period were prospectively included in the study. Results One hundred thirty-one patients were included in the study, which showed that in-hospital mortality increases uniformly with the severity of the coronary artery lesion (p = 0.044), but an effect of revascularization on number of deaths was not observed (p = 0.64). The presence of coma (p = 0.005) and the combination of male sex and age above 60-year as 2.2-fold (p = 0.048) increasing in-hospital mortality were found. The highest mortality rate occurred during the first 3 days and the death rate of the patients who survived this period is low. We found reduced left ventricular ejection fraction (OR = 6.54; 95% CI: 1.98-21.63; p = 0.002), non-ventricular fibrillation initial rhythm (OR = 2.94; 95% CI: 1.25-6.90; p = 0.014), unconscious at admission (OR = 6.46; 95% CI: 1.96-21.24; p = 0.002) and post-resuscitation coma (OR = 6.00; 95% CI: 2.63-13.66; p < 0.001) or encephalopathy (OR = 2.71; 95% CI: 1.9-6.72; p = 0.031) to be significant prognostic factors for higher in-hospital mortality rate. Conclusions We recommend immediate coronary interventions for all survivors of OHCA regardless of their state of consciousness and absence of ischaemic changes on ECG. Early intensive treatment for OHCA patients is indispensable, as the highest mortality rate is within the first 3 days after an event.
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Temperature management for out-of-hospital cardiac arrest. JAAPA 2018; 30:30-36. [PMID: 29210906 DOI: 10.1097/01.jaa.0000526776.92477.c6] [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
More than 300,000 Americans suffer a cardiac arrest outside of the hospital each year and even among those who are successfully resuscitated and survive to hospital admission, outcomes remain poor. Temperature management (previously known as therapeutic hypothermia) is the only intervention that has been reproducibly demonstrated to ameliorate the neurologic injury that follows cardiac arrest. The results of a recent large randomized controlled trial have highlighted the uncertainty about temperature management strategies following cardiac arrest. This article reviews the issues and recommendations.
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Elmer J, Callaway CW, Chang CCH, Madaras J, Martin-Gill C, Nawrocki P, Seaman KAC, Sequeira D, Traynor OT, Venkat A, Walker H, Wallace DJ, Guyette FX. Long-Term Outcomes of Out-of-Hospital Cardiac Arrest Care at Regionalized Centers. Ann Emerg Med 2018; 73:29-39. [PMID: 30060961 DOI: 10.1016/j.annemergmed.2018.05.018] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/04/2018] [Accepted: 05/16/2018] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVE It is unknown whether regionalization of postarrest care by interfacility transfer to cardiac arrest receiving centers reduces mortality. We seek to evaluate whether treatment at a cardiac arrest receiving center, whether by direct transport or early interfacility transfer, is independently associated with long-term outcome. METHODS We performed a retrospective cohort study including adults resuscitated from out-of-hospital cardiac arrest in southwestern Pennsylvania and neighboring Ohio, West Virginia, and Maryland, which includes approximately 5.7 million residents in urban, suburban, and rural counties. Patients were treated by 1 of 78 ground emergency medical services agencies or 2 air medical transport agencies between January 1, 2010, and November 30, 2014. Our primary exposures of interest were interfacility transfer to a cardiac arrest receiving center within 24 hours of arrest or any treatment at a cardiac arrest receiving center regardless of transfer status. Our primary outcome was vital status, assessed through December 31, 2014, with National Death Index records. We used unadjusted and adjusted survival analyses to test the independent association of cardiac arrest receiving center care, whether through direct or interfacility transport, on mortality. RESULTS Overall, 5,217 cases were observed for 3,629 person-years, with 3,865 total deaths. Most patients (82%) were treated at 42 non-cardiac arrest receiving centers with median annual volume of 17 cases (interquartile range 1 to 53 cases per center annually), whereas 18% were cared for at cardiac arrest receiving centers receiving at least 1 interfacility transfer per month. In adjusted models, treatment at a cardiac arrest receiving center was independently associated with reduced hazard of death compared with treatment at a non-cardiac arrest receiving center (adjusted hazard ratio 0.84; 95% confidence interval 0.74 to 0.94). These effects were unchanged when analysis was restricted to patients brought from the scene to the treating hospital. No other hospital characteristic, including total out-of-hospital cardiac arrest patient volume and cardiac catheterization capabilities, independently predicted outcome. CONCLUSION Both early interfacility transfer to a cardiac arrest receiving center and direct transport to a cardiac arrest receiving center from the scene are independently associated with reduced mortality.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Chung-Chou H Chang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jonathan Madaras
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Philip Nawrocki
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA
| | | | - Denisse Sequeira
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Owen T Traynor
- Department of Emergency Medicine, St. Clair Hospital, Pittsburgh, PA
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA
| | - Heather Walker
- Department of Emergency Medicine, Excela Health, Greensburg, PA
| | - David J Wallace
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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McCarthy JJ, Carr B, Sasson C, Bobrow BJ, Callaway CW, Neumar RW, Ferrer JME, Garvey JL, Ornato JP, Gonzales L, Granger CB, Kleinman ME, Bjerke C, Nichol G. Out-of-Hospital Cardiac Arrest Resuscitation Systems of Care: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e645-e660. [DOI: 10.1161/cir.0000000000000557] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The American Heart Association previously recommended implementation of cardiac resuscitation systems of care that consist of interconnected community, emergency medical services, and hospital efforts to measure and improve the process of care and outcome for patients with cardiac arrest. In addition, the American Heart Association proposed a national process to develop and implement evidence-based guidelines for cardiac resuscitation systems of care. Significant experience has been gained with implementing these systems, and new evidence has accumulated. This update describes recent advances in the science of cardiac resuscitation systems and evidence of their effectiveness, as well as recent progress in dissemination and implementation throughout the United States. Emphasis is placed on evidence published since the original recommendations (ie, including and since 2010).
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Chang BL, Mercer MP, Bosson N, Sporer KA. Variations in Cardiac Arrest Regionalization in California. West J Emerg Med 2018; 19:259-265. [PMID: 29560052 PMCID: PMC5851497 DOI: 10.5811/westjem.2017.10.34869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 10/14/2017] [Accepted: 10/11/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction The development of cardiac arrest centers and regionalization of systems of care may improve survival of patients with out-of-hospital cardiac arrest (OHCA). This survey of the local EMS agencies (LEMSA) in California was intended to determine current practices regarding the treatment and routing of OHCA patients and the extent to which EMS systems have regionalized OHCA care across California. Methods We surveyed all of the 33 LEMSA in California regarding the treatment and routing of OHCA patients according to the current recommendations for OHCA management. Results Two counties, representing 29% of the California population, have formally regionalized cardiac arrest care. Twenty of the remaining LEMSA have specific regionalization protocols to direct all OHCA patients with return of spontaneous circulation to designated percutaneous coronary intervention (PCI)-capable hospitals, representing another 36% of the population. There is large variation in LEMSA ability to influence inhospital care. Only 14 agencies (36%), representing 44% of the population, have access to hospital outcome data, including survival to hospital discharge and cerebral performance category scores. Conclusion Regionalized care of OHCA is established in two of 33 California LEMSA, providing access to approximately one-third of California residents. Many other LEMSA direct OHCA patients to PCI-capable hospitals for primary PCI and targeted temperature management, but there is limited regional coordination and system quality improvement. Only one-third of LEMSA have access to hospital data for patient outcomes.
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Affiliation(s)
- Brian L Chang
- University of California San Francisco School of Medicine, Department of Emergency Medicine, San Francisco, California
| | - Mary P Mercer
- University of California San Francisco School of Medicine, Department of Emergency Medicine, San Francisco, California
| | - Nichole Bosson
- Los Angeles County Emergency Medical Service Agency, Los Angeles, California.,Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute, Carson, California
| | - Karl A Sporer
- University of California San Francisco School of Medicine, Department of Emergency Medicine, San Francisco, California.,Alameda County Emergency Medical Service Agency, Alameda, California
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Shavelle DM, Bosson N, Thomas JL, Kaji AH, Sung G, French WJ, Niemann JT. Outcomes of ST Elevation Myocardial Infarction Complicated by Out-of-Hospital Cardiac Arrest (from the Los Angeles County Regional System). Am J Cardiol 2017; 120:729-733. [PMID: 28728743 DOI: 10.1016/j.amjcard.2017.06.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/16/2017] [Accepted: 06/01/2017] [Indexed: 01/01/2023]
Abstract
The objective of this study was to evaluate the time to primary percutaneous coronary intervention (PCI) and the outcome for patients with ST elevation myocardial infarction (STEMI) complicated by out-of-hospital cardiac arrest (OHCA). In this regional system, all patients with STEMI and/or OHCA with return of spontaneous circulation were transported to STEMI Receiving Centers. The outcomes registry was queried for patients with STEMI with underwent primary PCI from April 2011 to December 2014. Patients with STEMI complicated by OHCA were compared with a reference group of STEMI without OHCA. The primary end point was the first medical contact-to-device time. Of 4,729 patients with STEMI who underwent primary PCI, 422 patients (9%) suffered OHCA. Patients with OHCA were on average 2 years (95% confidence interval 0.7 to 3.0) older and had a slightly higher male predominance. The first medical contact-to-device time was longer in STEMI with OHCA compared with STEMI alone (94 ± 37 vs. 86 ± 34 minutes, p < 0.0001). In-hospital mortality was higher after OHCA, 38% versus 6% in STEMI alone, odds ratio 6.3 (95% confidence interval 5.3 to 7.4). Among OHCA survivors, 193 (73%) were discharged with a cerebral performance category score of 1 or 2. In conclusion, despite longer treatment intervals, neurologic outcome was good in nearly half of the surviving patients with STEMI complicated by OHCA, suggesting that these patients can be effectively treated with primary PCI in a regionalized system of care.
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Affiliation(s)
- David M Shavelle
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, California.
| | - Nichole Bosson
- Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, California; Department of Emergency Medicine, Harbor-UCLA Medical Centre and the Los Angeles Biomedical Institute, Torrance, California; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Joseph L Thomas
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Division of Cardiology, Harbor-UCLA Medical Centre and the Los Angeles Biomedical Institute, Torrance, California
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Centre and the Los Angeles Biomedical Institute, Torrance, California; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Gene Sung
- Department of Neurology, University of Southern California, Los Angeles, California
| | - William J French
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Division of Cardiology, Harbor-UCLA Medical Centre and the Los Angeles Biomedical Institute, Torrance, California
| | - James T Niemann
- Department of Emergency Medicine, Harbor-UCLA Medical Centre and the Los Angeles Biomedical Institute, Torrance, California; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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Postreanimationsbehandlung. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0331-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Gueret RM, Bailitz JM, Sahni AS, Tulaimat A. Therapeutic hypothermia at an urban public hospital: Development, implementation, experience and outcomes. Heart Lung 2017; 46:40-45. [DOI: 10.1016/j.hrtlng.2016.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 09/27/2016] [Accepted: 09/28/2016] [Indexed: 01/10/2023]
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Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care. Neurocrit Care 2016; 24:90-6. [PMID: 26264064 DOI: 10.1007/s12028-015-0184-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Therapeutic hypothermia (TH) improves neurologic outcome in patients resuscitated from ventricular fibrillation. The purpose of this study was to evaluate TH effects on neurologic outcome in patients resuscitated from a non-shockable out-of-hospital cardiac arrest rhythm. DESIGN AND SETTING This is a retrospective cohort study of data reported to a registry in an emergency medical system in a large metropolitan region. Patients achieving field return of spontaneous circulation are transported to designated hospitals with TH protocols. PATIENTS Patients with an initial non-shockable rhythm were identified. Patients were excluded if awake in the Emergency Department or if TH was withheld due to preexisting coma or death prior to initiation. The decision to initiate TH was determined by the treating physician. MEASUREMENTS The primary outcome was survival with good neurologic outcome defined by a cerebral performance category of 1 or 2. MAIN RESULTS Of the 2772 patients treated for cardiac arrest during the study period, there were 1713 patients resuscitated from cardiac arrest with an initial non-shockable rhythm and 1432 patients met inclusion criteria. The median age was 69 years [IQR 59-82]; 802 (56%) male. TH was induced in 596 (42%) patients. Survival with good neurologic outcome was 14% in the group receiving TH, compared with 5% in those not treated with TH (risk difference = 8%, 95% CI 5-12%). The adjusted OR for a CPC 1 or 2 with TH was 2.9 (95% CI 1.9-4.4). CONCLUSION Analyzing the data collected from the registry of the standard practice in a large metropolitan region, TH is associated with improved neurologic outcome in patients resuscitated from initial non-shockable rhythms in a regionalized system for post-resuscitation care.
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Epidemiology of Emergency Medical Services (EMS) Utilization in Four Indian Emergency Departments. Prehosp Disaster Med 2016; 31:675-679. [PMID: 27640552 DOI: 10.1017/s1049023x16000959] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Introduction Without a universal Emergency Medical Services (EMS) system in India, data on the epidemiology of patients who utilize EMS are limited. This retrospective chart review aimed to quantify and describe the burden of disease and patient demographics of patients who arrived by EMS to four Indian emergency departments (EDs) in order to inform a national EMS curriculum. METHODS A retrospective chart review was performed on patients transported by EMS over a three-month period in 2014 to four private EDs in India. A total of 17,541 patient records were sampled from the four sites over the study period. Of these records, 1,723 arrived by EMS and so were included for further review. RESULTS A range of 1.4%-19.4% of ED patients utilized EMS to get to the ED. The majority of EMS patients were male (59%-64%) and adult or geriatric (93%-99%). The most common chief complaints and ED diagnoses were neurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease. CONCLUSIONS Neurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease are the most common problems found in patients transported by EMS in India. Adult and geriatric male patients are the most common EMS utilizers. Emergency Medical Services curricula should emphasize these knowledge areas and skills. Wijesekera O , Reed A , Chastain PS , Biggs S , Clark EG , Kole T , Chakrapani AT , Ashish N , Rajhans P , Breaud AH , Jacquet GA . Epidemiology of Emergency Medical Services (EMS) utilization in four Indian emergency departments. Prehosp Disaster Med. 2016;31(6):675-679.
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Elmer J, Rittenberger JC, Coppler PJ, Guyette FX, Doshi AA, Callaway CW. Long-term survival benefit from treatment at a specialty center after cardiac arrest. Resuscitation 2016; 108:48-53. [PMID: 27650862 DOI: 10.1016/j.resuscitation.2016.09.008] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/30/2016] [Accepted: 09/05/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The Institute of Medicine and American Heart Association have called for tiered accreditation standards and regionalization of post-cardiac arrest care, but there is little data to support that regionalization has a durable effect on patient outcomes. We tested the effect of treatment at a high-volume center on long-term outcome after sudden cardiac arrest (SCA). METHODS We included patients hospitalized at one of 7 medical centers in Southwestern Pennsylvania after SCA from 2005 to 2013. Centers were one regional referral center with an organized systems for post-SCA care, two moderate volume tertiary care centers and 4 low-volume centers. We abstracted clinical characteristics and outcomes at hospital discharge, and for survivors to discharge we queried the National Death Index for long-term survival data. We used Cox regression to determine the unadjusted associations of baseline predictors and survival, and built an adjusted model controlling for baseline predictors. RESULTS Overall, 987 patients survived to discharge. During 2196 person-years of follow-up, median survival was 5.3 years and there were 396 deaths. In unadjusted analysis, treating center, age, arrest location, Charlson Comorbidity Index, initial rhythm, cardiac catheterization, defibrillator placement, discharge disposition, and neurological status at discharge were associated with long-term outcome. In adjusted analysis, treatment at the high-volume cardiac arrest center was associated with improved survival compared to treatment at other centers (hazards ratio 1.49, 95% confidence interval 1.19-1.86). CONCLUSION Treatment at a high-volume cardiac arrest center with organized systems for post-arrest care is associated with a substantial long-term survival benefit after hospital discharge.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh PA, United States; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh PA, United States.
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh PA, United States
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh PA, United States; Department of Physician Assistant Studies, University of the Sciences, Philadelphia, PA, United States
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh PA, United States
| | - Ankur A Doshi
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh PA, United States
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh PA, United States
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Bosson N, Kaji AH, Fang A, Thomas JL, French WJ, Shavelle D, Niemann JT. Sex Differences in Survival From Out-of-Hospital Cardiac Arrest in the Era of Regionalized Systems and Advanced Post-Resuscitation Care. J Am Heart Assoc 2016; 5:JAHA.116.004131. [PMID: 27633392 PMCID: PMC5079051 DOI: 10.1161/jaha.116.004131] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate sex differences in out-of-hospital cardiac arrest (OHCA) characteristics, interventions, and outcomes. METHODS AND RESULTS This is a retrospective analysis from a regionalized cardiac arrest system. Data on patients treated for OHCA are reported to a single registry, from which all adult patients were identified from 2011 through 2014. Characteristics, treatment, and outcomes were evaluated with stratification by sex. The adjusted odds ratio (OR) for survival with good neurological outcome (cerebral performance category 1 or 2) was calculated for women compared to men. There were 5174 out-of-hospital cardiac arrests (OHCAs; 3080 males and 2094 females). Women were older, median 71 (interquartile range [IQR], 59-82) versus 66 years (IQR, 55-78). Despite similar frequency of witnessed arrest, women were less likely to present with a shockable rhythm (22% vs 35%; risk difference [RD], 13%; 95% CI, 11-15), have ST-segment elevation myocardial infarction (23% vs 32%; RD, 13%; 95% CI, 7-11), or receive coronary angiography (11% vs 25%; RD, 14%; 95% CI, 12-16), percutaneous coronary intervention (5% vs 14%; RD, 9%; 95% CI, 7-11), or targeted temperature management (33% vs 40%; RD, 7%; 95% CI, 4-10). Women had decreased survival to discharge (33% vs 40%; RD, 7%; 95% CI, 4-10) and a lower proportion of good neurological outcome (16% vs 24%; RD, 8%; 95% CI, 6-10). In multivariable modeling, female sex was not associated with decreased survival with good neurological outcome (OR, 0.9; 95% CI, 0.8-1.1). CONCLUSIONS Sex-related differences in OHCA characteristics and treatment are predictors of survival outcome disparities. With adjustment for these factors, sex was not associated with survival or neurological outcome after OHCA.
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Affiliation(s)
- Nichole Bosson
- Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, CA Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA The David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Amy H Kaji
- Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA The David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Joseph L Thomas
- Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA The David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - William J French
- Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA The David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - David Shavelle
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - James T Niemann
- Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA The David Geffen School of Medicine at UCLA, Los Angeles, CA
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Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, Bottiger BW, Friberg H, Sunde K, Sandroni C. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2016; 95:202-22. [PMID: 26477702 DOI: 10.1016/j.resuscitation.2015.07.018] [Citation(s) in RCA: 734] [Impact Index Per Article: 91.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK.
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Alain Cariou
- Cochin University Hospital (APHP) and Paris Descartes University, Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
| | - Véronique R M Moulaert
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care and NIHR Southampton Respiratory Biomedical Research Unit, University Hospital, Southampton, UK
| | - Bernd W Bottiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Hans Friberg
- Department of Clinical Sciences, Division of Anesthesia and Intensive Care Medicine, Lund University, Lund, Sweden
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
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Merlo AE, Chauhan D, Pettit C, Hong KN, Saunders CR, Chen C, Russo MJ. Outcomes following emergent open repair for thoracic aortic dissection are improved at higher volume centers in direct admissions and transfers. J Cardiothorac Surg 2016; 11:118. [PMID: 27484472 PMCID: PMC4969670 DOI: 10.1186/s13019-016-0529-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 07/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study is (1) to define the proportion of patients undergoing emergent open repair of thoracic aortic dissection admitted directly through the emergency room versus those transferred from outside hospitals and (2) to determine if a volume-outcomes relationship exists for those patients across admission types. METHODS De-identified patient-level data was obtained from the Nationwide Inpatient Sample (2004-2008). Patients undergoing emergent aortic surgery for thoracic aortic dissection (n = 1,507) were identified by ICD-9 codes and stratified by annual center volume into low volume (≤5 cases/year) (n = 963; 63.9 %), intermediate volume (6-10 cases/year) (n = 370; 24.5 %), and high volume (≥11 cases/year) (n = 174; 11.6 %) groups. The analysis was further stratified by admission type: direct admission (DA), transfer admission (TA), and other. The primary outcome was in-hospital mortality. Multivariate logistic regression analysis was performed comparing outcomes between high vs low and high vs intermediate volume centers. RESULTS Overall in-hospital mortality was 21.8 % (n = 328/1,507). Absolute percent mortality at high volume centers was significantly lower (12.6 %) than at medium (20.6 %) and low volume (23.9 %) centers. For DA patients, mortality was 10.6, 21.4, and 24.0 % for high, medium, and low volume centers respectively. For TA patients, mortality was 10.2, 12.7, and 23.5 % for high, medium, and low volume centers, respectively. Multivariate analysis suggested that patients in low volume center were more likely to die compared to high volume center (Odds Ratio 2.06, 95 % CI 1.25 - 3.38, p = 0.004). Admission source was not associated with increased mortality. CONCLUSIONS Direct admissions comprise the largest proportion of dissections regardless of volume strata, and they comprise the largest proportion in the low and intermediate volume cohorts. Admission to low volume center is an independent risk factor for increased mortality. Patients transferred to high volume centers from low volume centers have similar outcome as direct admits in terms of mortality.
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Affiliation(s)
- Aurelie E Merlo
- Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Dhaval Chauhan
- Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA. .,Department of Surgery, Rutgers - New Jersey Medical School, Newark, NJ, USA. .,Newark Beth Israel Medical Center, Barnabas Health Heart Centers, 201 Lyons Ave, Suite G5, Newark, NJ, 07112, USA.
| | - Chris Pettit
- Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA
| | - Kimberly N Hong
- Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, NY, USA
| | - Craig R Saunders
- Newark Beth Israel Medical Center, Barnabas Heart Hospitals, Newark, NJ, USA
| | - Chunguang Chen
- Newark Beth Israel Medical Center, Barnabas Heart Hospitals, Newark, NJ, USA
| | - Mark J Russo
- Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA.,Department of Surgery, Rutgers - New Jersey Medical School, Newark, NJ, USA.,Newark Beth Israel Medical Center, Barnabas Heart Hospitals, Newark, NJ, USA
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Bosson NE, Kaji AH, Koenig WJ, Niemann JT. Effect of Therapeutic Hypothermia on Survival and Neurologic Outcome in the Elderly. Ther Hypothermia Temp Manag 2016; 6:71-5. [DOI: 10.1089/ther.2015.0030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nichole E. Bosson
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
- Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, California
| | - Amy H. Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - William J. Koenig
- Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, California
| | - James T. Niemann
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
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Kajino K, Kitamura T, Kiyohara K, Iwami T, Daya M, Ong MEH, Shimazu T, Sadamitsu D. Temporal Trends in Outcomes after Out-of-Hospital Cardiac Arrests Witnessed by Emergency Medical Services in Japan: A Population-Based Study. PREHOSP EMERG CARE 2016; 20:477-84. [PMID: 26852940 DOI: 10.3109/10903127.2015.1115931] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Survival after out-of-hospital cardiac arrests (OHCA) witnessed by emergency medical service (EMS) personnel has been insufficiently understood. The aim of this study was to evaluate temporal trends in survival after EMS-witnessed OHCAs in Japan. METHODS A nationwide, population-based, observational cohort study of consecutive adult OHCA patients with emergency responder resuscitation attempts from January 2005 to December 2012 in Japan. We assessed the trends in annual incidence, characteristics, and outcomes of OHCA patients witnessed by EMS personnel. Multiple logistic regression analysis was used to assess factors that were potentially associated with neurologically favorable outcome defined as cerebral performance category scale 1or 2. RESULTS During the study period, a total of 66,760 EMS-witnessed OHCAs were documented. The annual incidence rates per 100,000 persons of EMS-witnessed OHCA patients increased from 4.6 (n = 7219) in 2005 to 4.9 (n = 9256) in 2012 (p for trend = 0.035). The proportion of one-month survival with neurologically favorable outcome improved from 5.9% in 2005 to 8.6% in 2012 (p for trend < 0.001), and the proportion increased from 22.1% in 2005 to 30.2% in 2012 in cases with shockable rhythm (p for trend < 0.001). In a multivariate analysis, adults, male gender, shockable rhythm, presumed cardiac origin, and year were associated with a better neurological outcome. CONCLUSIONS In this population, the proportion of one-month survival with neurologically favorable outcome among OHCA patients witnessed by EMS personnel significantly improved during the study period.
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Greif R, Lockey A, Conaghan P, Lippert A, De Vries W, Monsieurs K. Ausbildung und Implementierung der Reanimation. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0092-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kronick SL, Kurz MC, Lin S, Edelson DP, Berg RA, Billi JE, Cabanas JG, Cone DC, Diercks DB, Foster J(J, Meeks RA, Travers AH, Welsford M. Part 4: Systems of Care and Continuous Quality Improvement. Circulation 2015; 132:S397-413. [DOI: 10.1161/cir.0000000000000258] [Citation(s) in RCA: 191] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Greif R, Lockey AS, Conaghan P, Lippert A, De Vries W, Monsieurs KG, Ballance JH, Barelli A, Biarent D, Bossaert L, Castrén M, Handley AJ, Lott C, Maconochie I, Nolan JP, Perkins G, Raffay V, Ringsted C, Soar J, Schlieber J, Van de Voorde P, Wyllie J, Zideman D. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2015; 95:288-301. [DOI: 10.1016/j.resuscitation.2015.07.032] [Citation(s) in RCA: 272] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Association between treatment at an ST-segment elevation myocardial infarction center and neurologic recovery after out-of-hospital cardiac arrest. Am Heart J 2015; 170:516-23. [PMID: 26385035 DOI: 10.1016/j.ahj.2015.05.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 05/29/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND For patients resuscitated from out-of-hospital cardiac arrest (OHCA), the American Heart Association recommends regionalized care at cardiac resuscitation centers that are aligned with ST-segment elevation myocardial infarction (STEMI) centers. The effectiveness of treatment at STEMI centers remains unknown. OBJECTIVE To evaluate whether good neurologic recovery after OHCA is associated with treatment at an STEMI center and if volume of admitted OHCA patients is associated with good neurologic recovery. METHODS We included patients in the 2011 California Office of Statewide Health Planning and Development database with a "present on admission" diagnosis of cardiac arrest. Primary outcome was good neurologic recovery at hospital discharge. Hierarchical multiple logistic regression models were used to determine the association between treating hospital and good neurologic recovery after adjusting for patient factors (age, sex, race, ethnicity, insurance type, and ventricular arrest rhythm) and hospital factors (hospital size, intensive care unit bed days, trauma center designation, and teaching status). RESULTS We included 7,725 patients; two-thirds (5,202) were treated at an STEMI center and 1,869 (24%, 95% CI 23%-25%) had good neurologic recovery. After adjustment, treatment at an STEMI center with ≥40 and <40 OHCA cases/year were associated with good neurologic recovery (odds ratio 1.32 [95% CI 1.06-1.64] and 1.63 [95% CI 1.35-1.97], respectively). Higher volume of admitted OHCA patients was associated with decreased odds of good neurologic recovery (adjusted odds ratio per 10 patients 0.96, 95% CI 0.92-1.00), but this association was not statistically significant after excluding the highest-volume outlier. CONCLUSIONS Treatment at an STEMI center-regardless of its annual OHCA volume-after resuscitation from OHCA is associated with good neurologic recovery. Regionalized systems of care should prioritize STEMI centers as destinations for resuscitated OHCA patients.
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Eckstein M, Schlesinger SA, Sanko S. Interfacility Transports Utilizing the 9-1-1 Emergency Medical Services System. PREHOSP EMERG CARE 2015; 19:490-5. [PMID: 25909809 DOI: 10.3109/10903127.2015.1005258] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND With the increasing development of regional specialty centers, emergency physicians are often confronted with patients needing definitive care unavailable at their hospital. Interfacility transports (IFTs) may be a useful option to ensure timely, definitive patient care. However, since traditional IFT can be a challenging and time-consuming process, some EMS agencies that have previously limited their service to 9-1-1 emergency responses are now performing emergency IFTs. OBJECTIVE We sought to determine the frequency and nature of transfers provided by a local fire-based 9-1-1 EMS agency that recently began to provide limited IFT for time-critical emergencies. METHODS A retrospective review of paramedic reports for all IFTs between April 2007 and March 2014 in the City of Los Angeles, California. All IFTs initiated by 9-1-1 call from an emergency department (ED) and performed by Los Angeles Fire Department paramedics were included. Reason for transfer, patient demographics, and key time metrics were captured. RESULTS There were 919 IFTs during the study period, out of approximately 1,160,000 total ambulance transports (0.1%). The most frequent reason for IFT request was for transport of patients with ST segment elevation MI (STEMI) to a STEMI receiving center, followed by major trauma to a trauma center, and intracranial hemorrhage to a center with neurosurgical capability. Less common reasons included vascular emergencies, acute stroke, obstetric emergencies, and transfers to pediatric critical care facilities. Median transport time was 8 minutes (IQR 6-13 minutes) and median total time for IFT was 51 minutes (IQR 39-69 minutes). All IFTs involved a potentially life-threatening condition requiring a higher level of care than was available at the referring hospital. CONCLUSIONS Emergent ED-to-ED interfacility transport can provide access to time critical definitive care. EMS agencies that have limited the scope of their response to community 9-1-1 emergencies should have policies in place to assure timely response for emergent IFT requests.
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Treatment and outcomes of ST segment elevation myocardial infarction and out-of-hospital cardiac arrest in a regionalized system of care based on presence or absence of initial shockable cardiac arrest rhythm. Am J Cardiol 2014; 114:968-71. [PMID: 25118120 DOI: 10.1016/j.amjcard.2014.07.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 07/02/2014] [Accepted: 07/02/2014] [Indexed: 11/23/2022]
Abstract
The aim of this study was to evaluate the treatment and outcomes of patients with ST-segment elevation myocardial infarctions complicated by out-of-hospital cardiac arrest in a regional system of care. In this retrospective study, the effect of the absence of an initial shockable arrest rhythm was analyzed. The primary end point of survival with good neurologic outcome in patients with and without an initial shockable arrest rhythm was adjusted for age, witnessed arrest, bystander cardiopulmonary resuscitation, and treatment with therapeutic hypothermia and percutaneous coronary intervention. One-hundred sixty-eight of 348 patients (49%) survived to hospital discharge. Patients with a shockable initial rhythm were more likely to receive therapeutic hypothermia (48% vs 37%, risk ratio 1.2, 95% confidence interval [CI] 1.0 to 1.5) and to be treated in the cardiac catheterization laboratory (80% vs 43%, risk ratio 2.8, 95% CI 2.0 to 3.8). The likelihood of survival with good neurologic outcome in patients with a shockable initial rhythm compared with those presenting without a shockable rhythm was 4.8 (95% CI 2.7 to 8.7). In patients who underwent percutaneous coronary intervention, the likelihood of survival with good neurologic outcome was higher (risk ratio 2.7, 95% CI 1.1 to 6.8) in those with a shockable rhythm. In conclusion, the absence of an initial shockable rhythm in patients with ST-segment elevation myocardial infarctions plus out-of-hospital cardiac arrest is associated with significantly worse survival and neurologic outcome. These differences persist despite application of therapies including therapeutic hypothermia and percutaneous coronary intervention within a regionalized system of care.
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Mumma BE, Diercks DB, Holmes JF. Availability and utilization of cardiac resuscitation centers. West J Emerg Med 2014; 15:758-63. [PMID: 25493115 PMCID: PMC4251216 DOI: 10.5811/westjem.2014.8.21877] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/18/2014] [Accepted: 08/20/2014] [Indexed: 11/13/2022] Open
Abstract
Introduction The American Heart Association (AHA) recommends regionalized care following out-of-hospital cardiac arrest (OHCA) at cardiac resuscitation centers (CRCs). Key level 1 CRC criteria include 24/7 percutaneous coronary intervention (PCI) capability, therapeutic hypothermia capability, and annual volume of ≥40 patients resuscitated from OHCA. Our objective was to characterize the availability and utilization of resources relevant to post-cardiac arrest care, including level 1 CRCs in California. Methods We combined data from the AHA, the California Office of Statewide Health Planning and Development (OSHPD), and surveys to identify CRCs. We surveyed emergency department directors and nurse managers at all 24/7 PCI centers identified by the AHA to determine their post-OHCA care capabilities. The survey included questions regarding therapeutic hypothermia use and specialist availability and was pilot-tested prior to distribution. Cases of OHCA were identified in the 2011 OSHPD Patient Discharge Database using a “present on admission” diagnosis of cardiac arrest (ICD-9-CM code 427.5). We defined key level 1 CRC criteria as 24/7 PCI capability, therapeutic hypothermia, and annual volume ≥40 patients admitted with a “present on admission” diagnosis of cardiac arrest. Our primary outcome was the proportion of hospitals meeting these criteria. Descriptive statistics and 95% CI are presented. Results Of the 333 acute care hospitals in California, 31 (9.3%, 95% CI 6.4–13%) met level 1 CRC criteria. These hospitals treated 25% (1937/7780; 95% CI 24–26%) of all admitted OHCA patients in California in 2011. Of the 125 hospitals identified as 24/7 PCI centers by the AHA, 54 (43%, 95% CI 34–52%) admitted ≥40 patients following OHCA in 2011. Seventy (56%, 95% CI 47–65%) responded to the survey; 69/70 (99%, 95% CI 92–100%) reported having a therapeutic hypothermia protocol in effect by 2011. Five percent of admitted OHCA patients (402/7780; 95% CI 4.7–5.7%) received therapeutic hypothermia and 18% (1372/7780; 95% CI 17–19%) underwent cardiac catheterization. Conclusion Approximately 10% of hospitals met key criteria for AHA level 1 CRCs. These hospitals treated one-quarter of patients resuscitated from OHCA in 2011. The feasibility of regionalized care for OHCA requires detailed evaluation prior to widespread implementation.
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Affiliation(s)
- Bryn E Mumma
- University of California Davis, Department of Emergency Medicine, Sacramento, California
| | - Deborah B Diercks
- University of California Davis, Department of Emergency Medicine, Sacramento, California
| | - James F Holmes
- University of California Davis, Department of Emergency Medicine, Sacramento, California
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