Post-resuscitation care at the emergency department with critical care facilities – a length-of-stay analysis

doi:10.1016/j.resuscitation.2011.03.004

Resuscitation

Volume 82, Issue 7, July 2011, Pages 853-858

https://doi.org/10.1016/j.resuscitation.2011.03.004 Get rights and content

Abstract

Aim of the study

An emergency department providing critical care will have an effect on outcome and intensive-care-units’ resources by avoiding unnecessary or futile intensive-care admissions and thereby save hospital expenses. The study focussed on this result.

Methods

The study employed a retrospective analysis of prospectively collected data of out-of-hospital cardiac arrest patients with return of spontaneous circulation, comatose on arrival. Outcomes and length of stay of patients who either stayed at the ‘emergency department only’ or were ‘transferred in addition to an intensive care unit’ were compared. Linear regression with log length of stay as outcome and ‘emergency department only’ as predictor with covariates was used for modelling.

Results

From 1991 to 2008, out of 1236 patients (age 57 ± 15 years, female 31%), the ‘emergency department only’ group (n = 349 (28%)) survived to discharge in 81(23%) cases, with a median length-of-stay in critical care of 1.7 (interquartile range 0.8; 3.1) days. The patients ‘transferred in addition to an intensive care unit’ (n = 887 (72%)), with a survival rate of 55% (n = 486, p < 0.001) stayed 10 (5; 18) days (p < 0.001). The length-of-stay in hospital was significantly shorter if patients were treated in the ‘emergency department only’ independent of other cardiac-arrest-related factors (regression coefficient −1.42, confidence interval −1.60 to −1.24).

Conclusions

An emergency department with critical care prevents admissions to intensive care units in 28% of patients with out-of-hospital cardiac arrest. It saves intensive-care-unit resources and shortens length of stay for comatose out-of-hospital cardiac-arrest survivors, regardless of their outcome.

Section snippets

Methods

This study was a retrospective cohort analysis based on a prospectively designed and conducted registry of patients resuscitated from cardiac arrests in an urban population and admitted to a department of emergency medicine at a tertiary care centre. The procedures were in accordance with the ethical standards of the committee on human experimentation. Adult patients suffering out-of-hospital cardiac arrest between September 1991 and May 2008 were eligible, regardless of the aetiology of

Statistical analysis

Analysis was performed comparing a group of patients receiving postresuscitation care at the ‘emergency department only’ until admission to an open ward, discharge home or death with a second group of patients ‘transferred in addition to an intensive care unit’ as the primary exposure. We report continuous variables as means ±standard deviation or as medians and 25–75% interquartile ranges, depending on actual data distribution. Categorical variables are reported as counts and percentages.

Results

A total of 2190 Utstein records were assessed for eligibility, resulting in 1450 patients with out-of-hospital cardiac arrest with primary successful resuscitation attempts. Due to admission to an external facility, 61 patients did not meet the inclusion criteria. Of the remaining 1389 patients, 153 were not comatose and therefore not eligible. Thus, the 1236 remaining comatose out-of-hospital cardiac-arrest survivors were further analysed. Of these patients, 349 (28%) received

Discussion

Comatose patients after out-of-hospital cardiac arrest, who achieved restoration of spontaneous circulation and were admitted to the emergency department, received postresuscitation care either only at the emergency department or in addition after being transferred to the intensive care unit. The emergency department with a high frequency of cardiac-arrest cases, and critical-care capability has proven that unnecessary admission to the intensive care units could be avoided. Treatment at the

Conclusions

Intensive-care-unit resources can be saved by providing postresuscitation care at an emergency department with a high frequency of out-of-hospital cardiac-arrest cases and critical-care capabilities, as almost one-third of comatose out-of-hospital cardiac-arrest survivors did not need an intensive-care-unit admission. Providing critical care at the emergency department seems to save hospital resources. Further investigations concerning the role of cardiac-arrest-care centres for hospital

Conflict of interest statement

The authors do not have any conflict of interest related to the topics in this article.

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This may have occurred because ED survival is not currently listed in the Utstein OHCA template.14 Two previous reports demonstrate wide variability in ED mortality (between 22 %15 and 74 %16), although the data used in both of these studies is more than a decade old and the reasons for deaths in ED are currently unreported. This study aims to fill these gaps by: (1) describing ED outcomes and causes of ED deaths overall and by status on arrival; and (2) examining whether ED survival and causes of ED death varies between hospital types.
The emergency department (ED) plays an important role in out-hospital-cardiac arrest (OHCA) management. However, ED outcomes are not widely reported. This study aimed to (1) describe OHCA ED outcomes and reasons for ED deaths, and (2) whether these differed between hospitals.
Data were obtained from the Victorian Ambulance Cardiac Arrest Registry and 12 hospitals for adult, non-traumatic OHCA cases transported to ED between 2014 and 2016. Multivariable logistic regression was used to examine the association of level of cardiac arrest centre on ED survival in a subset of cases (non-paramedic witnessed OHCA who were unconscious on ED arrival with ROSC).
Of 1547 eligible OHCA cases, 81% (N = 1254) survived ED, varying between 57% to 88% between EDs. Among non-survivors, the majority had either: cessation of resuscitation after presenting with CPR in progress (27%); withdrawal of life-sustaining treatment for non-neurological (n = 65, 22%) or neurological (16%) reasons; or a unsuccessful resuscitation following a rearrested in ED (20%). These causes of ED deaths varied between the different levels of cardiac arrest centres, and in our subset of interest (n = 952) ED survival was associated with transportation to centres with high annual OHCA volumes and with 24-hour cardiac intervention capabilities (AOR = 3.43, 95% CI 1.89–6.21).
Our study found wide variation in survival between EDs, which was associated with hospital characteristics. Such data suggests the need for a detailed review of ED deaths, particularly in non-cardiac arrest centres, and potentially the need for monitoring ED survival as a measure of quality.
Admission of out-of-hospital cardiac arrest victims to a high volume cardiac arrest center is linked to improved outcome
2016, Resuscitation
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The registry was founded to enable an increase in awareness of good quality CPR and provide detailed feedback to enable benchmarking for the EMS of the city of Vienna. All data were documented prospectively according to Utstein style criteria with structured protocols as reported elsewhere.29 This study was a prospective cohort analysis based on data obtained from this registry.
Cardiac arrest centers have been associated with improved outcome for patients after cardiac arrest. Aim of this study was to investigate the effect on outcome depending on admission to high-, medium- or low volume centers.
Analysis from a prospective, multicenter registry for out of hospital cardiac arrest patients treated by the emergency medical service of Vienna, Austria. The frequency of cardiac arrest patients admitted per center/year (low <50; medium 50–100; high >100) was correlated to favorable outcome (30-day survival with cerebral performance category of 1 or 2).
Out of 2238 patients (years 2013–2015) with emergency medical service resuscitation, 861 (32% female, age 64 (51;73) years) were admitted to 7 different centers. Favorable outcome was achieved in 267 patients (31%). Survivors were younger (58 vs. 66 years; p < 0.001), showed shockable initial heart rhythm more frequently (72 vs. 35%; p < 0.001), had shorter CPR durations (22 vs. 29 min; p < 0.001) and were more likely to be treated in a high frequency center (OR 1.6; CI: 1.2–2.1; p = 0.001).
In multivariate analysis, age below 65 years (OR 15; CI: 3.3–271.4; p = 0.001), shockable initial heart rhythm (OR 10.1; CI: 2.4–42.6; p = 0.002), immediate bystander or emergency medical service CPR (OR 11.2; CI: 1.4–93.3; p = 0.025) and admission to a center with a frequency of >100 OHCA patients/year (OR 5.2; CI: 1.2–21.7; p = 0.025) was associated with favorable outcome.
High frequency of post-cardiac arrest treatment in a specialized center seems to be an independent predictor for favorable outcome in an unselected population of patients after out of hospital cardiac arrest.
The association between systolic blood pressure on arrival at hospital and outcome in adults surviving from out-of-hospital cardiac arrests of presumed cardiac aetiology
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Previous studies have mostly relied on measurements taken either in the first hours/day after ICU arrival,7–9,11 by which time SBP is likely to be higher or more invasively monitored. These studies will also have excluded the 28% of patients who are not admitted to ICU,23 such as those dying in the emergency department or those not requiring an ICU level of care (i.e. patients with brief arrests). However, despite these differences in timing of measurement and in study populations, most studies to date have found a significant association with post-ROSC hypotension and patient outcome.
The optimal blood pressure target following successful resuscitation from out-of-hospital cardiac arrest (OHCA) is uncertain. This study aimed to explore the association between level of systolic blood pressure (SBP) on arrival at hospital and survival to hospital discharge.
We analysed eligible OHCAs occurring between January 2003 and December 2011 from the Victorian Ambulance Cardiac Arrest Register (VACAR). Inclusion criteria were: adults (≥18 years), presumed cardiac aetiology, not paramedic witnessed, and ROSC at hospital arrival. Multivariate logistic regression models were performed by initial rhythm (shockable/non-shockable) to examine the relationship between SBP at hospital arrival in 10 mmHg increments and survival to hospital discharge. Models were adjusted for known predictors of survival, including duration of arrest.
Of 3620 eligible cases, 14% were hypotensive (SBP < 90 mmHg) on hospital arrival (10% shockable and 19% non-shockable). For patients in shockable rhythms, discharge survival was maximal at 120–129 mmHg (54%), and in the adjusted model (≥120 mmHg as reference) SBP decrements below 90 mmHg were associated with lower survival: 80–89 mmHg AOR = 0.49 (95% CI: 0.24–0.95); <80 mmHg AOR = 0.24 (95% CI: 0.10–0.61); unrecordable AOR = 0.10 (95% CI: 0.04–0.30). In patients found in non-shockable rhythms, SBP was not significant associated with discharge survival (AOR = 1.01, 95% CI: 0.89–1.15).
In an EMS system using intravenous adrenaline and fluids to maintain post-resuscitation SBP at 120 mmHg, hypotension on hospital arrival was relatively uncommon. However, in presumed cardiac OHCA patients with an initial shockable rhythm, SBPs below 90 mmHg was associated with significant lower odds of survival to hospital discharge. This level of hypotension may indicate patients who require more aggressive post-resuscitation blood pressure management.
ED intensivists and ED intensive care units
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Outcomes after fixation of rib fractures sustained during cardiopulmonary resuscitation: A retrospective single center analysis
2023, Frontiers in Surgery
Non-traumatic resuscitation room management: Structure, organization, and initial measures
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^☆: A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.03.004.

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Clinical paperPost-resuscitation care at the emergency department with critical care facilities – a length-of-stay analysis☆

Abstract

Aim of the study

Methods

Results

Conclusions

Section snippets

Methods

Statistical analysis

Results

Discussion

Conclusions

Conflict of interest statement

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Ann Emerg Med

Emerg Med Clin North Am

Resuscitation

Resuscitation

Resuscitation

Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest

Acta Anaesthesiol Scand

Effects of bystander first aid, defibrillation and advanced life support on neurologic outcome and hospital costs in patients after ventricular fibrillation cardiac arrest

Intensive Care Med

A national analysis of the relationship between hospital factors and post-cardiac arrest mortality

Intensive Care Med

Clinical paper
Post-resuscitation care at the emergency department with critical care facilities – a length-of-stay analysis☆