Clinical paperTertiary centres have improved survival compared to other hospitals in the Copenhagen area after out-of-hospital cardiac arrest☆
Introduction
Out-of-hospital cardiac arrest (OHCA) is associated with a dismal prognosis even if patients are successfully resuscitated and admitted to hospital. However, in-hospital mortality differs markedly among available studies from 75% to 99%.1, 2, 3 Pre-hospital factors such as age, primary rhythm, time from alarm to arrival of the mobile emergency care unit (MECU), early defibrillation, witnessed cardiac arrest and whether bystander cardiopulmonary resuscitation (CPR) is performed are known to be important predictors of outcome.3, 4, 5, 6, 7 Major improvements in the pre-hospital care have contributed to the fact that the ‘chain of survival’ has increased survival rates to hospital admission.2, 8
The recent advanced life support guidelines from 2010 focus on the importance of post-resuscitation care in an attempt to further improve outcome after OHCA. Post-resuscitation care has now been included as the fourth circle in the chain-of-survival and the main focus is to support brain, heart, lung and kidney function in addition to preventing bacteraemia in order to prevent metabolic and haemodynamic disturbances frequently developing as part of a post-cardiac arrest syndrome.9, 10, 11
Several studies have found significant differences in mortality after OHCA that are not explained by the pre-hospital circumstances or risk factors for developing cardiac arrest.1, 2, 7, 12, 13, 14, 15 Although no single factor could be derived from these studies we hypothesized that the level of post-resuscitation care could be an important prognostic factor.
The aim of this study was to investigate whether successfully resuscitated patients admitted to tertiary heart centres had lower mortality after OHCA compared with patients admitted to non-tertiary university hospitals.
Section snippets
Patients and study area
This study is a cohort analysis based on an OHCA registry; a consecutive collection of data of OHCA from June 1, 2002 to December 31, 2010 in the Copenhagen area and followed for up to 8.8 years, corresponding to 1370 person-years of follow-up.
The emergency medical service in Copenhagen is two-tiered and operates as a double dispatch service with simultaneous dispatch and covers the Copenhagen area of 675 km2 (260 miles2), which is inhabited by a total of 1.2 million people. An emergency ambulance
Results
A total of 3739 patients were attempted resuscitated after OHCA, of whom 1218 (33%) were successfully resuscitated with ROSC outside the hospital or had on-going CPR at arrival to hospital. Patients admitted with on-going CPR were: ntertiary = 36 and nnon-tertiary = 17, p = 0.04. Of the 1218 patients, 742 patients (61%) were admitted to tertiary heart centres and 476 (39%) to non-tertiary university hospitals (Fig. 1). Seven patients were transferred from a non-tertiary university hospital to a
Discussion
Admission to a tertiary heart centre after successful resuscitation from OHCA is associated with a lower 30-day and long-term mortality. The difference in mortality remains clinically and statistically significant after exclusion of patients with ST-segment elevation myocardial infarction, adjustment for differences in confounding factors known to influence outcome, including patient characteristics, initial handling of the cardiac arrest and whether or not and when an acute coronary
Funding
None.
Conflict of interest statement
All authors are current employees of tertiary heart centres in Copenhagen.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.06.029.