Clinical paperThe feasibility of a regional cardiac arrest receiving system☆
Introduction
Out-of-hospital cardiac arrest (OOHCA) remains a leading cause of morbidity and mortality.1 Rapid response by emergency medical services (EMS) to provide cardiopulmonary resuscitation (CPR), including early defibrillation, is one of the links in the “chain of survival” defined by the American Heart Association (AHA).2, 3, 4, 5 A target response interval of 8 min has been defined, with recent data confirming the efficacy of early defibrillation.6, 7, 8, 9, 10, 11 In addition to minimizing response times, the EMS approach to OOHCA encourages rapid transport to the closest emergency department (ED) if resuscitative efforts are to be continued or to provide post-resuscitative care to patients with return of spontaneous circulation (ROSC).12, 13
The specific capabilities of the receiving ED and hospital have not been addressed. However, several therapies have recently been identified that may improve outcomes from OOHCA.14 Sophisticated intensive care is imperative in the post-resuscitative management of OOHCA victims due to the likelihood of recurrent arrest and the high incidence of an associated acute coronary event.15, 16, 17 In addition, recent data suggest that emergency primary coronary intervention (PCI) may benefit victims of OOHCA with ROSC.18, 19, 20, 21 This intervention may not be available in all receiving facilities, as only a minority of the nation's hospitals have cardiac catheterization laboratories and specialists on/call 24/7. Finally, several controlled trials have demonstrated the efficacy of induced hypothermia in successfully resuscitated patients.22, 23, 24 However, the technical challenges of inducing, maintaining, and monitoring the complications of hypothermia have limited its widespread use.25, 26
The emergence of post-resuscitative therapies raises the question as to whether cardiac arrest receiving facilities for OOHCA should be designated as part of a regional system. Before such a system could be implemented, two specific safety issues must be addressed. First, the impact of bypassing EDs that are not designated as cardiac arrest receiving facilities on patients without ROSC is unclear, although existing evidence suggests that more survivors of OOHCA are resuscitated in the field rather than the ED.12, 27, 28 In addition, longer transport times for patients with prehospital ROSC may place them at higher risk for deterioration en route to the ED. The objectives of this analysis were to explore each of these issues in a large, urban EMS system by determining the rate of survival for patients without prehospital ROSC as well as the relationship between transport time and outcome. This represents the primary analysis of the San Diego Cardiac Arrest Study, which enrolled data from OOHCA victims prospectively using the Utstein template. A sub-group analysis from this study focusing on patients with ventricular fibrillation (VF) was published previously.29
Section snippets
Design
This was a prospective, observational study conducted over an 18-month period from January 2001 through June 2002. The Investigational Review Board from each of the receiving hospitals granted waiver of consent.
Setting
San Diego Medical Services Enterprise (SDMSE) is a public–private partnership between the San Diego Fire-Rescue Department and Rural/Metro Ambulance Company. SDMSE is the exclusive provider of Advanced Life Support (ALS) services to a population of 1.3 million people in an area of 73
Results
A total of 1141 patients were enrolled over the 18-month period. Demographics, initial rhythm, incidence of prehospital ROSC, and disposition are displayed in Table 1. The final disposition based on initial rhythm is displayed in Table 2. A flow diagram demonstrating the incidence of prehospital ROSC for all patients based on final disposition is displayed in Figure 1. Only two patients who ultimately survived to hospital discharge did not have prehospital ROSC. Of note, four patients had
Discussion
We present cardiac arrest outcomes from a large, urban EMS system, demonstrating that survival from OOHCA is almost completely dependent upon prehospital ROSC. This is consistent with prior studies demonstrating the importance of prehospital ROSC to outcome and the futility of transport and continued resuscitation in the ED for most victims of OOHCA.12, 27, 28, 31, 32, 33, 34 In addition, transport interval duration does not appear to be associated with ultimate survival. This is consistent
Conclusions
We present cardiac arrest outcomes data from a large, urban EMS system. The vast majority of OOHCA victims who survive to discharge have ROSC in the field. In addition, transport time does not appear to influence outcome in patients who have ROSC. These findings support the feasibility of a regional cardiac arrest system.
Acknowledgements
The authors would like to express their appreciation to the following groups for their assistance in completing this project: the paramedics of San Diego County, San Diego Fire-Rescue Department, Rural/Metro Ambulance Company, San Diego Medical Services Enterprise, the San Diego County Base Hospital Nurse Coordinators, the San Diego County Base Station Physicians Committee, and San Diego County Emergency Medical Services Branch. In addition, we would like to thank the hospitals of San Diego
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2017, ResuscitationCitation Excerpt :Other a priori outcomes of interest were not reported in any of the included studies. Overall survival to discharge for all cardiac rhythms was less than 6% in seven studies [14–19,22]. One study reported a rate of survival to discharge of 35.1% in only OHCA patients with initial ventricular fibrillation [21].
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2006.11.009.