Elsevier

Resuscitation

Volume 73, Issue 1, April 2007, Pages 29-39
Resuscitation

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

https://doi.org/10.1016/j.resuscitation.2006.08.016Get rights and content

Summary

Background

Mortality among patients admitted to hospital after out-of-hospital cardiac arrest (OHCA) is high. Based on recent scientific evidence with a main goal of improving survival, we introduced and implemented a standardised post resuscitation protocol focusing on vital organ function including therapeutic hypothermia, percutaneous coronary intervention (PCI), control of haemodynamics, blood glucose, ventilation and seizures.

Methods

All patients with OHCA of cardiac aetiology admitted to the ICU from September 2003 to May 2005 (intervention period) were included in a prospective, observational study and compared to controls from February 1996 to February 1998.

Results

In the control period 15/58 (26%) survived to hospital discharge with a favourable neurological outcome versus 34 of 61 (56%) in the intervention period (OR 3.61, CI 1.66–7.84, p = 0.001). All survivors with a favourable neurological outcome in both groups were still alive 1 year after discharge. Two patients from the control period were revascularised with thrombolytics versus 30 (49%) receiving PCI treatment in the intervention period (47 patients (77%) underwent cardiac angiography). Therapeutic hypothermia was not used in the control period, but 40 of 52 (77%) comatose patients received this treatment in the intervention period.

Conclusions

Discharge rate from hospital, neurological outcome and 1-year survival improved after standardisation of post resuscitation care. Based on a multivariate logistic analysis, hospital treatment in the intervention period was the most important independent predictor of survival.

Introduction

Despite science based guidelines for cardiopulmonary resuscitation (CPR),1 the survival rate after out-of-hospital cardiac arrest (OHCA) has not improved much over the last decade.1, 2 The guidelines focus mainly on treatment until return of spontaneous circulation (ROSC), due to scarcity of studies on the post resuscitation period.1 Therapeutic hypothermia is reported to improve survival and neurological outcome in patients with ventricular fibrillation.3, 4 Two non-intervention cohort studies reported significant inter-hospital differences in survival (for those admitted with ROSC) that could not be explained by pre-hospital factors.5, 6 In-hospital body temperature, seizures, blood glucose and base excess were related to outcome.6

In Oslo, survival of those admitted to the intensive care unit (ICU) with ROSC has stayed at 25–35%,6, 7, 8 similar to the 30% reported in 22,105 patients in UK,9 but lower than the 56% reported in Stavanger,6 with the best reported survival rate in Europe.10

Based on the assumption that in-hospital factors could be important, we designed a standardised treatment protocol including therapeutic hypothermia, percutaneous coronary intervention (PCI) – if indicated – and standardised goals for factors such as blood glucose, haemodynamics, ventilation and handling of seizures. With focus on better care and improved survival for OHCA patients admitted to hospital, this was implemented into our hospital system. Since it was a multivariate systems approach, patients could not be randomised to either receive the required treatment or not in the emergency department (ED) and intensive care unit (ICU). The results were therefore compared to patients admitted to Ulleval University Hospital (Ulleval) in a recently published study from the preceding period.6

Section snippets

Patients and methods

The Norwegian Board of Health, Norwegian Social Science Data Service and Regional Committee for Medical Research Ethics approved the study.

Patients admitted to Ulleval ICU

During the 20.5 months intervention period 61 patients with OHCA of cardiac aetiology were admitted to ICU with ROSC versus 58 in the 24 months control period (Figure 1). All survivors with a favourable neurological outcome in both groups were still alive 1-year after discharge (Figure 1, Table 1).

Significantly more patients survived with a favourable outcome in the intervention period compared to the control period; 34 of 61 (56%) versus 15 of 58 (26%), p < 0.001 (Table 2). Mean age (63 ± 14

Discussion

The 56% survival to hospital discharge with favourable neurological outcome and 1-year survival among OHCA patients admitted to ICU is high compared to our previous results6, 7, 8 and those results reported from other institutions.5, 9, 13, 14, 15, 16 The value of the CPC score on hospital discharge as an indicator of quality of life and cognitive function later in life has been questioned,17 but is still the standard evaluation tool recommended in the last ILCOR scientific statement for

Conclusions

Survival to hospital discharge with good neurological recovery, and 1-year survival, in patients admitted to the ICU after OHCA of cardiac aetiology, improved after implementation of a standardised post resuscitation care treatment protocol in our hospital. This protocol included therapeutic hypothermia, PCI, and a focus on goal-directed treatment for the reperfusion period. Due to the study design a cause-and-effect relationship cannot be firmly established, but the results are encouraging.

Conflicts of interest disclosures

Dr. Sunde has received research grants from Laerdal Foundation for Acute Medicine and Professor Steen is a member of the Board of Laerdal Medical.

Acknowledgments

We are greatly indebted to MSc Mitchell Loeb (Sintef, Health Research, Oslo) for skilful help with the statistical analyses. This study was supported by grants from Laerdal Foundation for Acute Medicine, Ulleval University Hospital Scientific Advisory Council and Health Region East.

References (43)

  • J.W. Hsu et al.

    Quality-of-life and formal functional testing of survivors of out-of-hospital cardiac arrest correlates poorly with traditional neurologic outcome scales

    Ann Emerg Med

    (1996)
  • I. Jacobs et al.

    Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa)

    Resuscitation

    (2004)
  • J. Herlitz et al.

    Factors at resuscitation and outcome among patients suffering from out of hospital cardiac arrest in relation to age

    Resuscitation

    (2003)
  • J.P. Campbell et al.

    Hawthorne effect: implications for prehospital research

    Ann Emerg Med

    (1995)
  • E.C. Keeley et al.

    Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials

    Lancet

    (2003)
  • B. Bendz et al.

    Long-term prognosis after out-of-hospital cardiac arrest and primary percutaneous coronary intervention

    Resuscitation

    (2004)
  • M.B. Skrifvars et al.

    A multiple logistic regression analysis of in-hospital factors related to survival at six months in patients resuscitated from out-of-hospital ventricular fibrillation

    Resuscitation

    (2003)
  • S. Bernard et al.

    Induced hypothermia using large volume, ice-cold intravenous fluid in comatose survivors of out-of-hospital cardiac arrest: a preliminary report

    Resuscitation

    (2003)
  • K.B. Kern et al.

    Myocardial dysfunction after resuscitation from cardiac arrest: an example of global myocardial stunning

    J Am Coll Cardiol

    (1996)
  • I. Laurent et al.

    Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest

    J Am Coll Cardiol

    (2002)
  • 2005 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations

    Resuscitation

    (2005)
  • Cited by (0)

    A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2006.08.016.

    View full text