Improving Postarrest Care Through Evidence-Based Common Sense

Abstract

Out-of-hospital cardiac arrest is an important public health challenge in the United States. Effective cardiac arrest treatment requires well-informed and action-oriented bystanders, highperforming emergency medical services (EMS), and attentive postarrest care. The latter component requires multidisciplinary coordination of numerous elements, including temperature management, cardiac assessment and intervention, ventilator management, hemodynamic optimization, and structured neurologic evaluation, among other supportive actions. This organization of multiple domains resembles other familiar models of care for time-critical conditions such as trauma, myocardial infarction, and stroke. Some experts advocate that EMS directly transport postarrest patients to regional centers where the personnel, equipment, and specific expertise exist, a course modeled after success in treating these conditions. In this issue of Annals, Spaite et al report on a statewide effort to regionalize out-of-hospital cardiac arrest care. After a stakeholder meeting in 2007, the Arizona Department of Public Health designated a network of cardiac receiving centers that offered specialized care for postarrest patients, including therapeutic hypothermia, early coronary angiography and percutaneous coronary intervention, and guideline-based critical care. EMS leaders directed the transport of postarrest patients—with or without return of circulation—to these centers. In an evaluation of 2,177 patients treated before and after implementation of this system, Spaite et al found that the regionalization strategy increased therapeutic hypothermia use from 0% to 44% and nearly tripled coronary angiography use. Outcome differences included a 61% improvement in survival across all rhythms and nearly doubled survival among victims with initially shockable rhythms. In short, regionalization affected care and improved important patient-centered measures. Critics will argue that the study by Spaite et al cannot demonstrate the effectiveness of regionalized postarrest care, notably because of the limits inherent in before-after designs, including the effect of secular trends and unmeasured confounders that could magnify the observed outcome effects.