Elsevier

Resuscitation

Volume 137, April 2019, Pages 102-115
Resuscitation

Review
Does care at a cardiac arrest centre improve outcome after out-of-hospital cardiac arrest? — A systematic review

https://doi.org/10.1016/j.resuscitation.2019.02.006Get rights and content

Abstract

Aim

To perform a systematic review to answer ‘In adults with attempted resuscitation after non-traumatic cardiac arrest does care at a specialised cardiac arrest centre (CAC) compared to care in a healthcare facility not designated as a specialised cardiac arrest centre improve patient outcomes?’

Methods

The PRISMA guidelines were followed. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 1st August 2018. Randomised controlled trials (RCTs) and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using ROBINS-I tool and GRADEpro respectively. Primary outcomes were survival to 30 days with favourable neurological outcomes and survival to hospital discharge with favourable neurological outcomes. Secondary outcomes were survival to 30 days, survival to hospital discharge and return of spontaneous circulation (ROSC) post-hospital arrival for patients with ongoing resuscitation. This systematic review was registered in PROSPERO (CRD 42018093369)

Results

We included data from 17 observational studies on out-of-hospital cardiac arrest (OHCA) patients in meta-analyses. Overall, the certainty of evidence was very low. Pooling data from only adjusted analyses, care at CAC was not associated with increased likelihood of survival to 30 days with favourable neurological outcome (OR 2.92, 95% CI 0.68–12.48) and survival to 30 days (OR 2.14, 95% CI 0.73–6.29) compared to care at other hospitals. Whereas patients cared for at CACs had improved survival to hospital discharge with favourable neurological outcomes (OR 2.22, 95% CI 1.74–2.84) and survival to hospital discharge (OR 1.85, 95% CI 1.46–2.34).

Conclusions

Very low certainty of evidence suggests that post-cardiac arrest care at CACs is associated with improved outcomes at hospital discharge. There remains a need for high quality data to fully elucidate the impact of CACs.

Introduction

There is wide variability in survival among hospitals caring for patients after resuscitation from out of hospital cardiac arrest (OHCA). OHCA is common, yet survival outcomes are poor, with substantial regional and international variation.1, 2, 3, 4, 5 Survival from OHCA ranges from 8–16.1%.6 Measures to maximise favourable neurological outcomes are a research priority for both patients and clinicians.7 Post-resuscitation care, including percutaneous coronary intervention (PCI) and targeted temperature measurement (TTM), is an important component to achieve good neurological outcome.8, 9

In most countries, post resuscitation care is not regionalized to specialised hospitals.10 There is wide variation among hospitals in the availability and type of post resuscitation care, as well as clinical outcomes.11, 12 Patients with other time-sensitive emergencies (e.g. trauma, acute myocardial infarction and stroke services) are often triaged to centres which offer speciality services and greater provider experience.13, 14, 15, 16 Such centralised specialist services may improve the provision of targeted post-resuscitation care and offer similar benefits and improve patient outcomes after cardiac arrest.

The International Liaison Committee on Resuscitation (ILCOR) last considered the evidence on this topic in 2015 and concluded that specialist cardiac arrest centres (CACs) may be effective despite a lack of high quality data to support their implementation.17 Previous observational studies have reported an association between transport to CAC and survival to hospital discharge, but there is inconsistency in the hospital factors that are related to optimal patient outcomes. Whilst most experts agree that a CAC should include a 24-h cardiac catheterisation laboratory, targeted temperature management, and neurological services that offer electrophysiological modalities for monitoring and prognostication, discrepancies remain in the definition of services that constitute a specialist CAC.18 The objective of this systematic review was to evaluate outcomes of adults with attempted OHCA resuscitation after care in a specialized cardiac arrest centre compared with care in an institute not designated as a specialized cardiac arrest centre.

Section snippets

Methods

The protocol for this systematic review was registered with PROSPERO (CRD 42018093369) on 12th April 2018. Reporting of the systematic review was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.19 The review was commissioned by ILCOR.

Results

After removal of duplicates, the literature search yielded 3065 unique references (3061 from original search and 4 additional studies from updated search). After screening, 22 studies (one randomised controlled trial,30 one prospective study, 4 before and after studies and 16 retrospective analyses) fulfilled eligibility criteria and were included in qualitative synthesis (Fig. 1). Studies were conducted in Australia (n = 3), North America (n = 8), Europe (n = 7) and South East Asia (n = 4).

Discussion

This is the most comprehensive and up to date systematic review and meta-analysis examining the impact of care at CACs compared with other hospitals on patient outcomes from OHCA. This review included data from large registries contributed by different countries. Patients cared for at CACs had increased likelihood of survival to hospital discharge and survival to hospital discharge with favourable neurological outcomes. However, there was no evidence that care at CACs improve survival to 30

Conclusions

Very low certainty evidence suggests that post-cardiac arrest care at cardiac arrest centres is associated with improved survival with favourable neurological outcome at hospital discharge and improved survival to hospital discharge. Care at CACs did not improve survival to 30 days with favourable neurological outcome and survival to 30 days. There remains a need of high quality data individual patient data meta-analysis and or data from randomised trials to fully elucidate the impact of CAC.

Conflicts of interest

Joyce Yeung was compensated by ILCOR for her work related to this review. TM and JB were authors of two studies included in this review. The other authors declare no competing conflict of interests.

Acknowledgments

This Systematic Review was funded by the American Heart Association, on behalf of The International Liaison Committee on Resuscitation (ILCOR) for manuscript submission to the editor. The following authors received payment from this funding source to complete this systematic review:

Joyce Yeung as Expert Systematic Reviewer.

Nazi Torabi and Glyneva Bradley-Ridout as Information Services, St Michael’s Hospital.

JY is supported by National Institute of Health Research Post-Doctoral Fellowship. JB is

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