Commentary and conceptsThe development and implementation of cardiac arrest centers☆
Section snippets
Overview
Patients with sustained return of spontaneous circulation (ROSC) after cardiac arrest exhibit a variety of specific responses to ischemia-reperfusion injury, often resulting in multi-system organ involvement requiring intervention by multiple medical specialties.1 Implementation of a comprehensive care plan for patients after cardiac arrest has been shown to lead to improved outcomes, and was recently promoted in the 2010 American Heart Association (AHA) guidelines.1, 2, 3 However, delivery of
Center concept
Within the past several years, several tertiary care centers have developed specialized teams and “Centers” to enhance the clinical care of post-cardiac arrest patients. The provision of specialized regional centers has emerged for the management of a number of critical illnesses such as stroke and trauma.6, 7, 8, 9 The emergence of specialized cardiac arrest centers will presumably lead to improved clinical care as well as the opportunity for increased research and education in a traditionally
Founding and development of the centers
All of the centers were founded through multidisciplinary collaboration with the main participants being clinicians representing emergency medicine, cardiology, pulmonary and critical care, and neurology. Virginia Commonwealth University first established a cardiac arrest center in 2003 followed shortly thereafter by the University of Pennsylvania in 2004. Beth Israel Deaconess Medical Center and the University of Pittsburgh (UPMC-Presbyterian Hospital) began development of their centers in
Multi-disciplinary participants
The management of post-cardiac arrest patients requires a strong multi-disciplinary approach with clinical and support services spanning both the inpatient and outpatient setting, with both physician and nursing input. Other groups that were involved at various centers include physical therapy and rehabilitation, occupational therapy, neuroradiology, neuropsychology, pharmacy, respiratory therapy, surgery, palliative care, pastoral care, social work, emergency medical services, toxicology, and
Overcoming obstacles
A number of obstacles arose at each of the four centers during the establishment phase. One obstacle experienced by the majority of the developing centers was the perception by some clinicians that cardiac arrest survivors almost invariably have poor outcomes and therefore there was concern over the allocation of time and provision of resources for “futile” therapies. In several centers, groups or individuals questioned the data in support of therapeutic hypothermia. Difficulty reaching
Clinical care services
Each of the cardiac arrest centers provide a series of organized clinical care services with a minimum of variation between groups. At three of the four centers, the cardiac intensive care unit (CICU) is the designated admission unit for post-arrest patients; occasionally, exception is made for various clinical reasons. The remaining center tends to manage patients with ventricular arrhythmias in the cardiac intensive care unit but those with the initial rhythm of pulseless electrical activity
Outcomes and feedback
All four centers expressed that hospital staff and administrators view their program positively. One center was awarded a “Patient Safety Quality Improvement Award” from within their hospital system and another center received a similar award through the Society of Critical Care Medicine with the support of the hospital administration. Three centers report an increase in outside referrals specifically for cardiac arrest since the inception of the center at the respective institutions. For
Research and educational mission
All four centers have a strong research mission, though only two (University of Pittsburgh and Virginia Commonwealth University) believes this is a necessary component in the development of a cardiac arrest center. Other models such as the one developed in Arizona (see specific section) are both community and academic-based. Three of four centers have a strong educational mission while the fourth center is currently establishing this aspect of their program. The leaders of all of the centers
Other models
One state, Arizona, has established an entire network of hospitals classified by a governing body as “Cardiac Receiving Centers” or “Cardiac Referral Centers” after meeting minimum qualifications. The qualifications to become a receiving center include:
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A method and protocol for therapeutic hypothermia treatment after out of hospital cardiac arrest (OHCA)
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Primary percutaneous coronary intervention (PCI) capability
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Capability to complete a data form following each OHCA to be sent to governing state
Conclusion
Patients who survive cardiac arrest and resuscitation are often critically ill and present significant challenges to the medical providers caring for them in the post-arrest period; these patients may benefit from being cared for in centers which have developed an expertise in treating this complex population. This paper has attempted to describe the approach of several hospitals across the United States, and may be a resource for other hospitals interested in developing their own cardiac
Conflict of interest statement
Clifton Callaway: Grant from NIH to conduct clinical trials in cardiac arrest and trauma. Patents related to defibrillation licensed to Medtronic. Loan of equipment to conduct laboratory studies of hypothermia from Medivance.
Michael W. Donnino and Michael Cocchi: Investigator-initiated grants from the NIH, American Heart Association, and the Laerdal Medical Foundation.
Jon Rittenberger: Funding from NAEMSP/Zoll Medical EMS Resuscitation Research Fellowship, NIH KL2 funding, loaned NIRS monitors
Acknowledgements
We thank additional members of the National Post-Arrest Research Consortium (NPARC):
Beth Israel Deaconess Medical Center: Donna Williams RN, Shelly Calder RN, Donald Cutlip MD, Eli Gelfand MD, Justin Salciccioli, Susan Herman MD, Michael Alexander MD, Praveen Akuthota MD, Peter Zimetbaum MD.
University of Pennsylvania: Lance Becker MD, Robert Neumar MD, PhD, Daniel Kolansky MD, Barry Fuchs MD, Raina Merchant MD, Brendan G Carr MD, Gail Delfin RN, Cheryl Maguire RN, MSN, Thomas Levins RN.
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Cited by (69)
External validation of Pittsburgh Cardiac Arrest Category illness severity score
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Survivorship After Sudden Cardiac Arrest: Establishing a Framework for Understanding and Care Optimization
2021, Journal of Cardiothoracic and Vascular AnesthesiaVariation in outcomes among 24/7 percutaneous coronary intervention centres for patients resuscitated from out-of-hospital cardiac arrest
2019, ResuscitationCitation Excerpt :Organisational culture is associated with performance in disease processes that overlap with OHCA, including acute myocardial infarction19,21,38,39 acute ischaemic stroke,40 and critical illness.41 Clinicians’ perception of futility in the care of patients resuscitated from OHCA was a barrier to implementation of specialised post-OHCA care at several hospitals37 and may contribute to the variation in outcomes seen in our study. Future studies should evaluate differences in organisational culture between 24/7 PCI centres with differential outcomes.
Association between percutaneous hemodynamic support device and survival from cardiac arrest in the state of Michigan
2018, American Journal of Emergency Medicine
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.03.021.
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For the National Post-Arrest Research Consortium (NPARC).