Clinical paperStrong and weak aspects of an established post-resuscitation treatment protocol—A five-year observational study☆
Introduction
Survival after out-of-hospital cardiac arrest (OHCA) depends on a well functioning chain of survival, both during out-of hospital resuscitation and the in-hospital post resuscitation phase.1 Regional variations in survival of OHCA2, 3 point toward a substantial potential to improving treatment regimes.4, 5
Large inter-hospital differences in discharge rates among patients admitted with OHCA,6, 7, 8 indicate possibilities for improved post-resuscitation care, and provide opportunities to identify valuable interventions through judicious study of in-hospital data. Poor survival rate among hospitalized OHCA patients in Oslo,8 provided such an incentive to research and develop a new standard operating procedure (SOP) for post resuscitation treatment. The SOP was implemented in conjunction with a clinical trial rigorously tracking both pre- and in-hospital factors, complications, and outcome in a prospective post resuscitation registry.9 Evaluating the implementation phase in a “before-and-after” study design revealed a doubling of survival rate.9 The SOP remained unchanged until 2009 and the post resuscitation registry was kept operational in order to monitor quality control of the treatment and secure an opportunity for further studies.
Based on these registry data we have evaluated protocol adherence and survival rates after five years with an established SOP. Three distinct patient categories are described based on early assessment in the emergency department (ED): conscious, comatose, and comatose patients receiving only palliative care. As patients regaining consciousness early are less likely to require treatment for post cardiac arrest syndrome,10 we focused on comatose patients receiving active treatment, evaluating pre- and in-hospital factors that affected prognostication, end-of-care decisions and clinical outcome.
Section snippets
Materials and methods
The Regional Committee for Medical Research Ethics approved this study and the scientific use of the hospital post-resuscitation registry data.
Results
In the 5½ year study period, 324 resuscitated OHCA patients were brought to Ulleval as the primary hospital. There were 70 patients with non-cardiac cause of arrest, of whom 64% (45/70) received MTH and 18% (14% favourable) survived to hospital discharge (Fig. 1). Among the remaining 254 patients with presumed cardiac aetiology four died prior to ICU admission and two were excluded due to being transferred abroad prior to final hospital discharge, leaving 248 patients eligible for inclusion in
Discussion
Survival with favourable outcome at hospital discharge after OHCA with cardiac aetiology remained unchanged throughout the five-year period. The 56% favourable outcome was the same as that reported for the initial implementation phase of our SOP, doubling the survival rate compared to historical controls.9 Among comatose patient receiving active treatment, 49% survived with favourable outcome and 6% survived with unfavourable neurology.
Identifying and amending the cause of arrest by coronary
Conclusion
The previously reported doubling in survival rate remained throughout the five-year period, demonstrating the usefulness of a standard operating treatment procedure for post resuscitation care. Establishing reliable indications for emergency coronary angiography and interventions after OHCA and validating prognostication rules in the MTH era are important challenges for future studies.
Conflict of interest statement
None of the authors had any conflict of interest.
Acknowledgements
We would like to thank professor Petter Andreas Steen for useful discussion and critique during drafting this manuscript. The study was supported by grants from Eastern Norway Regional Health Authority, Oslo University Hospital, and Anders Jahres Fund.
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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.2011.05.003.