Elsevier

Annals of Emergency Medicine

Volume 64, Issue 5, November 2014, Pages 496-506.e1
Annals of Emergency Medicine

Emergency medical services/original research
Statewide Regionalization of Postarrest Care for Out-of-Hospital Cardiac Arrest: Association With Survival and Neurologic Outcome

Presented at the European Resuscitation Congress, October 2012, Vienna, Austria; and the National Association of EMS Physicians annual scientific meeting, January 2013, Bonita Springs, FL.
https://doi.org/10.1016/j.annemergmed.2014.05.028Get rights and content

Study objective

For out-of-hospital cardiac arrest, authoritative, evidence-based recommendations have been made for regionalization of postarrest care. However, system-wide implementation of these guidelines has not been evaluated. Our hypothesis is that statewide regionalization of postarrest interventions, combined with emergency medical services (EMS) triage bypass, is associated with improved survival and neurologic outcome.

Methods

This was a prospective before-after observational study comparing patients admitted to cardiac receiving centers before implementation of the interventions (“before”) versus those admitted after (“after”). In December 2007, the Arizona Department of Health Services began officially recognizing cardiac receiving centers according to commitment to provide specified postarrest care. Subsequently, the State EMS Council approved protocols allowing preferential EMS transport to these centers. Participants were adults (≥18 years) experiencing out-of-hospital cardiac arrest of presumed cardiac cause who were transported to a cardiac receiving center. Interventions included (1) implementation of postarrest care at cardiac receiving centers focusing on provision of therapeutic hypothermia and coronary angiography or percutaneous coronary interventions (catheterization/PCI); and (2) implementation of EMS bypass triage protocols. Main outcomes included discharged alive from the hospital and cerebral performance category score at discharge.

Results

During the study (December 1, 2007, to December 31, 2010), 31 hospitals were recognized as cardiac receiving centers statewide. Four hundred forty patients were transported to cardiac receiving centers before and 1,737 after. Provision of therapeutic hypothermia among patients with return of spontaneous circulation increased from 0% (before: 0/145; 95% confidence interval [CI] 0% to 2.5%) to 44.0% (after: 300/682; 95% CI 40.2, 47.8). The post return of spontaneous circulation catheterization PCI rate increased from 11.7% (17/145; 95% CI 7.0, 18.1) before to 30.7% (210/684; 95% CI 27.3, 34.3) after. All-rhythm survival increased from 8.9% (39/440) to 14.4% (250/1,734; adjusted odds ratio [aOR]=2.22; 95% CI 1.47 to 3.34). Survival with favorable neurologic outcome (cerebral performance category score=1 or 2) increased from 5.9% (26/439) to 8.9% (153/1,727; aOR=2.26 [95% CI 1.37, 3.73]). For witnessed shockable rhythms, survival increased from 21.4% (21/98) to 39.2% (115/293; aOR=2.96 [95% CI 1.63, 5.38]) and cerebral performance category score=1 or 2 increased from 19.4% (19/98) to 29.8% (87/292; aOR=2.12 [95% CI 1.14, 3.93]).

Conclusion

Implementation of a statewide system of cardiac receiving centers and EMS bypass was independently associated with increased overall survival and favorable neurologic outcome. In addition, these outcomes improved among patients with witnessed shockable rhythms.

Introduction

Editor's Capsule Summary

What is already known on this topic

Expert postarrest care improves out-of-hospital cardiac arrest outcomes.

What question this study addressed

Does regionalization of postarrest care improve out-of-hospital cardiac arrest outcomes?

What this study adds to our knowledge

In this before-after analysis, a statewide strategy of EMS bypass to specialized postarrest care centers resulted in improved neurologically intact out-of-hospital cardiac arrest survival.

How this is relevant to clinical practice

If the results can be replicated, communities should consider out-of-hospital cardiac arrest care regionalization strategies.

For decades, out-of-hospital cardiac arrest has been a major focus of emergency medical services (EMS) systems, and several bystander and EMS interventions have been shown to improve outcomes.1, 2, 3, 4, 5, 6, 7, 8, 9, 10 In contrast, inhospital postarrest care of out-of-hospital cardiac arrest has historically received little attention. The consensus was that, if a patient was not “saved” in the field, the likelihood that hospital care would make any significant difference was very low.11, 12 However, in the late 1990s, major interest in postarrest care was sparked by observational studies showing a potential effect of inhospital interventions, even in some patients with major neurologic deficits.13, 14, 15, 16 There is an increasing amount of literature and consensus that specialized postarrest care, including therapeutic hypothermia and targeted temperature management, improves out-of-hospital cardiac arrest outcomes.17, 18, 19 In response, international recommendations for the use of therapeutic hypothermia were published.20, 21, 22 There is also an increasing amount of literature reporting that a wide range of interventions, combined with standardized comprehensive critical care, may improve outcome.15, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38

The literature showing that inhospital care significantly influences outcomes after out-of-hospital cardiac arrest has resulted in discussions in support of regionalizing postarrest care through EMS triage to specialized centers39, 40, 41, 42 and ultimately led to the American Heart Association policy statement on regionalization.43 However, direct evidence for the effect of widespread, multisystem regionalization on patient outcomes is lacking.

In 2004, the Arizona Department of Health Services developed a statewide partnership with EMS agencies and researchers focusing on out-of-hospital cardiac arrest. The net effect was improvement in bystander and EMS care that led to a tripling of survival statewide.7, 44, 45 In 2007, this partnership established criteria for a statewide network of specialized cardiac receiving centers that could provide therapeutic hypothermia, prompt percutaneous coronary interventions, and other guideline-based postarrest critical care. In 2008, protocols were developed allowing EMS to bypass local hospitals to preferentially transport patients to cardiac receiving centers.

The goal for this study was to evaluate whether statewide regionalization of postarrest interventions, combined with EMS triage, would be associated with improved survival and neurologic outcome. Here we report the outcomes of this effort.

Section snippets

Study Design

This was a prospective, multicenter, multisystem, before-after observational cohort analysis comparing outcomes in patients admitted to cardiac receiving centers during the period before implementation versus those admitted to the same hospitals after implementation.

Setting

Arizona had 6.4 million residents in 2010 (http://quickfacts.census.gov/qfd/states/04000.html), with 62 licensed acute care hospitals. The Arizona Department of Health Services establishes EMS protocols, scope of practice, and

Results

Thirty-one hospitals, serving approximately 80% of the state's population, were designated as cardiac receiving centers between December 2007 and November 2010. The median length of the before phase was 6 months (interquartile range 4 to 11); and of the after phase, 18 months (interquartile range 10 to 27). Detailed patient and event characteristics for before and after are shown in Table 1. The results of the final regression models for all-rhythms survival and neurologic outcome are shown in

Limitations

This study was not randomized. Thus, we can show only associations between outcomes and the intervention and cannot prove causal relationships. Randomization is theoretically the best design to assess the effect of regionalization. However, because regionalization includes a “bundle” (eg, therapeutic hypothermia, continuous catheterization/PCI availability, comprehensive critical care, EMS bypass), we believe that randomization is not feasible.

Another approach is to randomize agencies and

Discussion

Implementation of this regionalized system of care was associated with improvement in overall survival (aOR=2.22), survival among patients with witnessed ventricular fibrillation or ventricular tachycardia (aOR=2.96), and the odds of favorable neurologic outcome for both the all-rhythm cohort (aOR=2.26) and those with witnessed ventricular fibrillation or ventricular tachycardia (aOR=2.12; Figure). In addition, although not statistically significant, the rates of both survival and favorable

References (62)

  • J. Engdahl et al.

    Is hospital care of major importance for outcome after out-of-hospital cardiac arrest? experience acquired from patients with out-of-hospital cardiac arrest resuscitated by the same emergency medical service and admitted to one of two hospitals over a 16-year period in the municipality of Goteborg

    Resuscitation

    (2000)
  • A.E. Borger van der Burg et al.

    Impact of percutaneous coronary intervention or coronary artery bypass grafting on outcome after nonfatal cardiac arrest outside the hospital

    Am J Cardiol

    (2003)
  • K. Sunde et al.

    Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest

    Resuscitation

    (2007)
  • M. Ruiz-Bailen et al.

    Reversible myocardial dysfunction after cardiopulmonary resuscitation

    Resuscitation

    (2005)
  • K. Sung et al.

    Improved survival after cardiac arrest using emergent autopriming percutaneous cardiopulmonary support

    Ann Thorac Surg

    (2006)
  • G. Nichol et al.

    Systematic review of percutaneous cardiopulmonary bypass for cardiac arrest or cardiogenic shock states

    Resuscitation

    (2006)
  • V.R. Hosmane et al.

    Survival and neurologic recovery in patients with ST-segment elevation myocardial infarction resuscitated from cardiac arrest

    J Am Coll Cardiol

    (2009)
  • C. Lettieri et al.

    Emergency percutaneous coronary intervention in patients with ST-elevation myocardial infarction complicated by out-of-hospital cardiac arrest: early and medium-term outcome

    Am Heart J

    (2009)
  • D.W. Spaite et al.

    The impact of prehospital transport interval on survival in out-of-hospital cardiac arrest: implications for regionalization of post-resuscitation care

    Resuscitation

    (2008)
  • D.W. Spaite et al.

    Effect of transport interval on out-of-hospital cardiac arrest survival in the OPALS study: implications for triaging patients to specialized cardiac arrest centers

    Ann Emerg Med

    (2009)
  • D.P. Davis et al.

    The feasibility of a regional cardiac arrest receiving system

    Resuscitation

    (2007)
  • I.G. Stiell et al.

    The Ontario Prehospital Advanced Life Support (OPALS) study: rationale and methodology for cardiac arrest patients

    Ann Emerg Med

    (1998)
  • I.G. Stiell et al.

    The Ontario Prehospital Advanced Life Support (OPALS) study part II: rationale and methodology for trauma and respiratory distress patients. OPALS Study Group

    Ann Emerg Med

    (1999)
  • G. Belliard et al.

    Efficacy of therapeutic hypothermia after out-of-hospital cardiac arrest due to ventricular fibrillation

    Resuscitation

    (2007)
  • H.E. Wang et al.

    Distribution of specialized care centers in the United States

    Ann Emerg Med

    (2012)
  • M.T. Cudnik et al.

    Increasing hospital volume is not associated with improved survival in out of hospital cardiac arrest of cardiac etiology

    Resuscitation

    (2012)
  • M.S. Eisenberg et al.

    Cardiac resuscitation in the community. Importance of rapid provision and implications for program planning

    JAMA

    (1979)
  • R.O. Cummins et al.

    Improving survival from sudden cardiac arrest: the “chain of survival” concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association

    Circulation

    (1991)
  • T.D. Valenzuela et al.

    Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos

    N Engl J Med

    (2000)
  • B.J. Bobrow et al.

    Chest compression–only CPR by lay rescuers and survival from out-of-hospital cardiac arrest

    JAMA

    (2010)
  • I. Stiell et al.

    Health-related quality of life is better for cardiac arrest survivors who received citizen cardiopulmonary resuscitation

    Circulation

    (2003)
  • Cited by (133)

    View all citing articles on Scopus

    Please see page 497 for the Editor's Capsule Summary of this article.

    Supervising editors: Henry E. Wang, MD, MS; Donald M. Yealy, MD

    Author contributions: DWS, BJB, RAB, ABS, KBK, and GAE were responsible for study concept and design. BJB, VC, WH, and TM were responsible for acquisition of the data. DWS, BJB, US, RAB, ABS, KBK, VC, and GAE were responsible for analysis and interpretation of the data. DWS, BJB, and US were responsible for drafting the article. All authors were responsible for critical revision of the article for important intellectual content. US and VC were responsible for statistical analysis. DWS, BJB, and GAE were responsible for obtaining funding. US, VC, WH, and TM were responsible for administrative, technical, and material support. DWS and BJB were responsible for study supervision. DWS takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist and provided the following details: The University of Arizona receives funding from the Medtronic Foundation through the HeartRescue Grant to support community-based translation of resuscitation science, including the SHARE program and this study. This includes support for Drs. Spaite, Bobrow, Stolz, and Ewy.

    A feedback survey is available with each research article published on the Web at www.annemergmed.com.

    A podcast for this article is available at www.annemergmed.com.

    Arizona Cardiac Receiving Center Consortium participants are listed in the Appendix.

    View full text