Elsevier

Resuscitation

Volume 84, Issue 2, February 2013, Pages 162-167
Resuscitation

Clinical paper
Tertiary centres have improved survival compared to other hospitals in the Copenhagen area after out-of-hospital cardiac arrest

https://doi.org/10.1016/j.resuscitation.2012.06.029Get rights and content

Abstract

Aims

Out-of-hospital cardiac arrest (OHCA) has been reported to carry very varying morbidity and mortality. However, it remains unclear whether this is caused by intrinsic factors of the OHCA or due to the level of in-hospital care. The aim of this study is to compare 30-day and long-term mortality after OHCA at tertiary heart centres and non-tertiary university hospitals.

Methods and results

Data from the Copenhagen OHCA registry from June 2002 through December 2010 included a total of 1218 consecutive patients treated by the same mobile emergency care unit (MECU) with either return of spontaneous circulation (ROSC) or on-going resuscitation (n = 53) at hospital arrival. The MECU transported patients to the nearest hospital unless an ECG on scene suggested ST-segment elevation myocardial infarction, in which case patients were transported to the nearest tertiary centre for acute coronary angiography. Therefore, patients with ST-elevation myocardial infarction (n = 198) were excluded from the analysis. 30-day mortality was 56% vs. 76% and long term (up to 8 years) mortality was 78% vs. 94% for tertiary and non-tertiary hospitals, respectively, both p < 0.001. Multivariate analysis showed that admission to a non-tertiary hospital was independently associated with increased risk of death (HR = 1.32, 95% CI: 1.09–1.59, p = 0.004). Exclusion of patients with on-going resuscitation at admission resulted in HR = 1.34 (1.11–1.62), p = 0.003. A matched pair propensity score analysis of 255 patients confirmed the results of the proportional hazard analysis (HR = 1.35, 95% CI: 1.11–1.65 p = 0.003).

Conclusion

Admission to tertiary centres is associated with lower mortality rates after OHCA compared with non-tertiary hospitals.

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.

References (31)

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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.

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