Out-of-hospital Cardiac Arrest Care Research Articles

Multistate 5-Year Initiative to Improve Care for Out-of-Hospital Cardiac Arrest: Primary Results From the HeartRescue Project.

BackgroundThe HeartRescue Project is a multistate public health initiative focused on establishing statewide out‐of‐hospital cardiac arrest (OHCA) systems of care to improve case capture and OHCA care in the community, by emergency medical services (EMS), and at hospital level.Methods and ResultsFrom 2011 to 2015 in the 5 original HeartRescue states, all adults with EMS–treated OHCA due to a presumed cardiac cause were included. In an adult population of 32.8 million, a total of 64 988 OHCAs—including 10 046 patients with a bystander‐witnessed OHCA with a shockable rhythm—were treated by 330 EMS agencies. From 2011 to 2015, the case‐capture rate for all‐rhythm OHCA increased from an estimated 39.0% (n=6762) to 89.2% (n=16 103; P<0.001 for trend). Overall survival to hospital discharge was 11.4% for all rhythms and 34.0% in the subgroup with bystander‐witnessed OHCA with a shockable rhythm. We observed modest temporal increases in bystander cardiopulmonary resuscitation (41.8–43.5%, P<0.001 for trend) and bystander automated external defibrillator application (3.2–5.6%, P<0.001 for trend) in the all‐rhythm group, although there were no temporal changes in survival. There were marked all‐rhythm survival differences across the 5 states (8.0–16.1%, P<0.001) and across participating EMS agencies (2.7–26.5%, P<0.001).ConclusionsIn the initial 5 years, the HeartRescue Project developed a population‐based OHCA registry and improved statewide case‐capture rates and some processes of care, although there were no early temporal changes in survival. The observed survival variation across states and EMS systems presents a future challenge to elucidate the characteristics of high‐performing systems with the goal of improving OHCA care and survival.

LO68: Extracorporeal membrane oxygenation in the emergency department for resuscitation of out-of-hospital cardiac arrest patients: a systematic review

Introduction: With one person in Canada suffering an out-of-hospital cardiac arrest (OHCA) every 12 minutes and an estimated survival to hospital discharge with good neurologic function ranging from 3 to 16%, OHCA represents a major source of morbidity and mortality. An evolving adjunct for resuscitation of OHCA patients is the use of extracorporeal membrane oxygenation-assisted CPR (ECPR). The purpose of this systematic review is to investigate the survival to hospital discharge with good neurologic recovery in patients suffering from OHCA treated with ECPR compared to those who received standard advanced cardiac life support with conventional CPR (CCPR) alone. Methods: A systematic database search of both MEDLINE &amp;amp; EMBASE was performed up until September 2016 to identify studies with ≥5 patients reporting ECPR use in adults (age ≥16 years) with OHCA. Only studies reporting survival to hospital discharge were included. All identified studies were assessed independently using pre-determined inclusion criteria by two reviewers. Study quality and risk of bias were evaluated using the Newcastle Ottawa regulations assessment scale. Results: Of the 1065 records identified, 54 studies met all inclusion criteria. Inter-rater reliability was high with a kappa statistic of 0.85. The majority of studies were comprised of case series (n=45) of ECPR with 5 to 83 patients/study. Out of the 45 case series, 37 presented neurologic data at hospital discharge and demonstrated a broad range of patients surviving with good neurologic outcome (0 to 71.4%). Only 9 cohort studies with relevant control group (CCPR) were identified (38 to 21750 patients/study). Preliminary analysis demonstrated that 6 cohort studies were sufficient quality to compare ECPR to CCPR. All 6 studies showed significantly increased survival to hospital discharge with good neurologic recovery (ECPR 10.6 to 41.6% vs CCPR 1.5 to 7.7%, respectively). Conclusion: Given the paucity of studies using appropriate comparators to evaluate the impact of ECMO, our confidence in a clinically relevant difference in outcomes compared to current standards of care for OHCA remains weak. Interestingly, a limited number of studies with suitable controls demonstrated a potential benefit associated with ECPR in the management of OHCA in selected patients. In this state of equipoise, high quality RCT data is urgently needed.

Abstract 038: American Heart Association Mission: Lifeline Breakthrough Series Collaborative Improving the Survival Rates for Out of Hospital Cardiac Arrest by Focusing on Early CPR With an Emphasis on Chest Compressions

Introduction: Out-of-hospital cardiac arrest (OHCA) remains a highly morbid public health problem. Despite improving practices and clear guidelines, mortality from this condition remains high at 90%, with survivors often suffering from poor neurologic outcomes. To determine the feasibility of quality improvement collaboratives to narrow gaps between evidence-based practice and patient care for OHCA, we conducted a pilot study of the AHA Resuscitation Collaborative. Methods: Eight emergency medical service agencies participated in the quality improvement collaborative pilot project. We identified several OHCA performance measures to assess the quality of care, guide collaborative activities, and monitor change in performance over time. Over the course of four learning sessions, participants were trained in quality improvement and performance measurement, analyzed performance measure results, and shared successes and challenges. Results: Five remaining agencies underwent the process outlined in Figure 1. Adherence to performance measures, including compression rate compliance (Figure 2), improved over the course of the collaborative. Compression rate compliance in Figure 2 corresponds to the process improvement efforts of the Chesapeake Fire Department with achievement of goals for optimal range of chest compression rate between 100 and 120 compressions per minute during resuscitations. Conclusion: As demonstrated in Virginia, the collaborative approach was an effective framework to improve OHCA care. Improvement in performance measures, the evident commitment of dedicated peers and colleagues, consistent collaboration, and the effective diffusion of best practices all support the continued use of this model.

Doubling Cardiac Arrest Survival by 2020: Achieving the American Heart Association Impact Goal.

In 2010, the American Heart Association (AHA) Emergency Cardiovascular Care Committee (ECC) set a 10-year impact goal of doubling cardiac arrest survival by 2020. This goal was more ambitious than the overarching AHA impact goal to reduce death from heart disease and stroke by greater than or equal to 20% by 2020. It was hypothesized at the time that reaching this cardiac arrest impact goal was not dependent on new scientific discovery but could be achieved with full implementation of up-to-date clinical guidelines and adopting best practices for systems of care. This hypothesis was supported by the observation that there was significant variability in both in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) survival rates. In fact, the 2020 targets were already being achieved in the highest performing emergency medical services (EMS) systems and hospitals. To drive progress toward achieving these goals, the AHA ECC was restructured to increase its focus on implementation. This restructuring included creation of a Systems of Care Subcommittee charged with measurably improving the systems of care for OHCA and IHCA across the entire chain of survival. Restructuring has enabled ECC to focus on strategies that have the highest likelihood of improving outcomes, such as increasing bystander cardiopulmonary resuscitation (CPR) rates and automatic external defibrillator use, 911 dispatcher CPR instructions, CPR quality for trained providers, postcardiac arrest care, and reliable postcardiac arrest prognostication. Establishing a baseline and ongoing strategy to monitor progress toward the 2020 impact goal was the first challenge. For OHCA, the AHA initially relied on the ROC Epistry (Resuscitation Outcomes Consortium) for baseline and annual data on incidence and outcomes. Because of the cessation of National Institutes of Health funding, the ROC Epistry stopped collecting data in June 2015. In 2014, the AHA also began utilizing data from the CARES registry (Cardiac …

Prehospital critical care for out-of-hospital cardiac arrest: An observational study examining survival and a stakeholder-focused cost analysis.

BackgroundSurvival rates from out-of-hospital cardiac arrest (OHCA) remain low, despite remarkable efforts to improve care. A number of ambulance services in the United Kingdom (UK) have developed prehospital critical care teams (CCTs) which attend critically ill patients, including OHCA. However, current scientific evidence describing CCTs attending OHCA is sparse and research to date has not demonstrated clear benefits from this model of care.MethodsThis prospective, observational study will describe the effect of CCTs on survival from OHCA, when compared to advanced-life-support (ALS), the current standard of prehospital care in the UK. In addition, we will describe the association between individual critical care interventions and survival, and also the costs of CCTs for OHCA.To examine the effect of CCTs on survival from OHCA, we will use routine Utstein variables data already collected in a number of UK ambulance trusts. We will use propensity score matching to adjust for imbalances between the CCT and ALS groups. The primary outcome will be survival to hospital discharge, with the secondary outcome of survival to hospital admission.We will record the critical care interventions delivered during CCT attendance at OHCA. We will describe frequencies and aim to use multiple logistic regression to examine possible associations with survival.Finally, we will undertake a stakeholder-focused cost analysis of CCTs for OHCA. This will utilise a previously published Emergency Medical Services (EMS) cost analysis toolkit and will take into account the costs incurred from use of a helicopter and the proportion of these costs currently covered by charities in the UK.DiscussionPrehospital critical care for OHCA is not universally available in many EMS. In the UK, it is variable and largely funded through public donations to charities. If this study demonstrates benefit from CCTs at an acceptable cost to the public or EMS commissioners, it will provide a rationale to increase funding and service provision. If no clinical benefit is found, the public and charities providing these services can consider concentrating their efforts on other areas of prehospital care.Trial registrationISRCTN registry ID ISRCTN18375201.

The impact of a pre-hospital critical care team on survival from out-of-hospital cardiac arrest.

To assess the impact of a pre-hospital critical care team (CCT) on survival from out-of-hospital cardiac arrest (OHCA). We undertook a retrospective observational study, comparing OHCA patients attended by advanced life support (ALS) paramedics with OHCA patients attended by ALS paramedics and a CCT between April 2011 and April 2013 in a single ambulance service in Southwest England. We used multiple logistic regression to control for an anticipated imbalance of prognostic factors between the groups. The primary outcome was survival to hospital discharge. All data were collected independently of the research. 1851 cases of OHCA were included in the analysis, of which 1686 received ALS paramedic treatment and 165 were attended by both ALS paramedics and a CCT. Unadjusted rates of survival to hospital discharge were significantly higher in the CCT group, compared to the ALS paramedic group (15.8% and 6.5%, respectively, p<0.001). After adjustment using multiple logistic regression, the effect of CCT treatment was no longer statistically significant (OR 1.54, 95% CI 0.89-2.67, p=0.13). Subgroup analysis of OHCA with first monitored rhythm of ventricular fibrillation or pulseless ventricular tachycardia showed similar results. Pre-hospital critical care for OHCA was not associated with significantly improved rates of survival to hospital discharge. These results are in keeping with previously published studies. Further research with a larger sample size is required to determine whether CCTs can improve outcome in OHCA.

Availability and utilization of cardiac resuscitation centers.

IntroductionThe American Heart Association (AHA) recommends regionalized care following out-of-hospital cardiac arrest (OHCA) at cardiac resuscitation centers (CRCs). Key level 1 CRC criteria include 24/7 percutaneous coronary intervention (PCI) capability, therapeutic hypothermia capability, and annual volume of ≥40 patients resuscitated from OHCA. Our objective was to characterize the availability and utilization of resources relevant to post-cardiac arrest care, including level 1 CRCs in California.MethodsWe combined data from the AHA, the California Office of Statewide Health Planning and Development (OSHPD), and surveys to identify CRCs. We surveyed emergency department directors and nurse managers at all 24/7 PCI centers identified by the AHA to determine their post-OHCA care capabilities. The survey included questions regarding therapeutic hypothermia use and specialist availability and was pilot-tested prior to distribution. Cases of OHCA were identified in the 2011 OSHPD Patient Discharge Database using a “present on admission” diagnosis of cardiac arrest (ICD-9-CM code 427.5). We defined key level 1 CRC criteria as 24/7 PCI capability, therapeutic hypothermia, and annual volume ≥40 patients admitted with a “present on admission” diagnosis of cardiac arrest. Our primary outcome was the proportion of hospitals meeting these criteria. Descriptive statistics and 95% CI are presented.ResultsOf the 333 acute care hospitals in California, 31 (9.3%, 95% CI 6.4–13%) met level 1 CRC criteria. These hospitals treated 25% (1937/7780; 95% CI 24–26%) of all admitted OHCA patients in California in 2011. Of the 125 hospitals identified as 24/7 PCI centers by the AHA, 54 (43%, 95% CI 34–52%) admitted ≥40 patients following OHCA in 2011. Seventy (56%, 95% CI 47–65%) responded to the survey; 69/70 (99%, 95% CI 92–100%) reported having a therapeutic hypothermia protocol in effect by 2011. Five percent of admitted OHCA patients (402/7780; 95% CI 4.7–5.7%) received therapeutic hypothermia and 18% (1372/7780; 95% CI 17–19%) underwent cardiac catheterization.ConclusionApproximately 10% of hospitals met key criteria for AHA level 1 CRCs. These hospitals treated one-quarter of patients resuscitated from OHCA in 2011. The feasibility of regionalized care for OHCA requires detailed evaluation prior to widespread implementation.

Rationale, Methodology, Implementation, and First Results of the French Out-of-hospital Cardiac Arrest Registry

Introduction. Out-of-hospital cardiac arrest (OHCA) is an important public health issue with an estimated incidence of 50,000 cases per year in France. Community survival rates for OHCA are still low (approximately 5%). An effective, recognized way to study, assess, and improve OHCA care is to create a standard-format database. Objective. The aim of this work is to present the French OHCA registry (RéAC). Methods. RéAC is a secure, web-based data management system that was initiated in 2009 and deployed nationally in June 2012. The main goal of this registry is to improve the care and survival rate of OHCA patients. The survey form is in compliance with the requirements of French organizations and is organized in accordance with the Utstein universal style. RéAC provides real-time statistical analyses and enables all French mobile emergency and resuscitation services (MERS) to assess and improve their professional OHCA care practices. Results. In June 2012, the RéAC was nationally opened for all French MERSs. In June 2013, 221 of a possible 320 MERS participated in the RéAC. A total of 15,944 OHCA have been collected (14,939 cases closed with follow-up monitoring). The current rate of inclusion is approximately 1,500 cases per month. Since August 2012, the inclusion rate has increased by 9.5% per month, while the participation rate has increased by 9% per month. The first results show that the population is mainly male (65.4%) and the mean age is 65 ± 19 years. On MERS arrival, 73.5% of the patients were in asystole. The rates of return of spontaneous circulation, survival to hospital admission, and 30-day survival are low (respectively 21.1%, 17.2%, 4.6%). Of those who survived 30 days, 84.0% had a good neurological recovery. Conclusions. The RéAC registry is a reliable observation tool to improve public health management of OHCA. It provides relevant information to adapt or to develop diagnosis, treatments, and prognostic resources. Moreover, it enables the development of targeted awareness programs for the unique purpose of increasing the survival rates of OHCA patients.

Temporal Differences in Out-of-Hospital Cardiac Arrest Incidence and Survival

Understanding temporal differences in the incidence and outcomes of out-of-hospital cardiac arrest (OHCA) has important implications for developing preventative strategies and optimizing systems for OHCA care. We studied 18 588 OHCAs of presumed cardiac origin in patients aged ≥18 years who received resuscitative efforts by emergency medical services (EMS) and were enrolled in the Cardiac Arrest Registry to Enhance Survival (CARES) from October 1, 2005, to December 31, 2010. We evaluated temporal variability in OHCA incidence and survival to hospital discharge. There was significant variability in the frequency of OHCA by hour of the day (P<0.001), day of the week (P<0.001), and month of the year (P<0.001), with the highest incidence occurring during the daytime, from Friday to Monday, in December. Survival to hospital discharge was lowest for OHCA that occurred overnight (from 11:01 pm to 7 am; 7.1%) versus daytime (7:01 am to 3 pm; 10.8%) or evening (3:01 pm to 11 pm; 11.3%; P<0.001) and during the winter (8.8%) versus spring (11.1%), summer (11.0%), or fall (10.0%; P<0.001). There was no difference in survival to hospital discharge between OHCAs that occurred on weekends and weekdays (9.5% versus 10.4%, P=0.06). After multivariable adjustment for age, sex, race, witness status, layperson resuscitation, first monitored cardiac rhythm, and emergency medical services response time, compared with daytime and spring, survival to hospital discharge remained lowest for OHCA that occurred overnight (odds ratio, 0.81; 95% confidence interval, 0.70-0.95; P=0.008) and during the winter (odds ratio, 0.81; 95% confidence interval, 0.70-0.94; P=0.006), respectively. There is significant temporal variability in the incidence of and survival after OHCA. The relative contribution of patient pathophysiology, likelihood of the OHCA being observed, and prehospital and hospital-based resuscitative factors deserves further exploration.

Abstract 33: Survival from Out-of-Hospital Cardiac Arrest Is Lowest at Night: Findings from the Cardiac Arrest Registry to Enhance Survival (CARES)

Background: Understanding temporal variability in the incidence and outcomes of out-of-hospital cardiac arrest (OHCA) has important implications for pre-hospital resource planning and structuring systems for OHCA care. Methods: Using the Cardiac Arrest Registry to Enhance Survival (CARES) database, we studied patients with OHCA of presumed cardiac etiology who were treated by emergency medical services (EMS) from 10/2005 to 12/2010. Measures of pre-hospital care, survival to hospital discharge, and neurologic outcomes were compared between OHCA occurring during daytime (0701-1500h), evening (1501-2300h), and overnight (2301-0700h). Results: The frequency of OHCA varied significantly across time blocks with 7503 (40.4%) occurring during daytime, 6883 (37.0%) during evening, and 4202 (22.6%) occurring overnight (p&lt;0.0001). Compared with OHCA patients during daytime or evening, those with OHCA overnight were more likely to be younger, arrest at home, have an unwitnessed arrest, have a non-shockable initial rhythm, and were less likely to receive bystander CPR or AED use (Table). Time from 911 call to EMS arrival was longest at night. Survival to hospital discharge was lowest among overnight OHCA patients. There was no difference in frequency of favorable neurologic outcomes among survivors in the different time blocks. After controlling for differences in patient and arrest characteristics, with daytime as the reference, overnight OHCA was associated with lower survival (OR 0.74, 95% CI 0.63-0.87, p=0.0002), with similar survival for patients with OHCA during evening (OR 0.99, 95% CI 0.88-1.12, p=0.91). Conclusion: There is temporal variability in OHCA occurrence with the nadir in frequency occurring at night. OHCA at night is independently associated with lowest survival to hospital discharge. Underlying patient, EMS system, and hospital factors contributing to these observed findings requires further exploration.

Therapeutic Hypothermia After Out-of-Hospital Cardiac Arrest

Background— Therapeutic hypothermia (TH) improves survival and confers neuroprotection in out-of-hospital cardiac arrest (OHCA), but TH is underutilized, and regional systems of care for OHCA that include TH are needed. Methods and Results— The Cool It protocol has established TH as the standard of care for OHCA across a regional network of hospitals transferring patients to a central TH-capable hospital. Between February 2006 and August 2009, 140 OHCA patients who remained unresponsive after return of spontaneous circulation were cooled and rewarmed with the use of an automated, noninvasive cooling device. Three quarters of the patients (n=107) were transferred to the TH-capable hospital from referring network hospitals. Positive neurological outcome was defined as Cerebral Performance Category 1 or 2 at discharge. Patients with non–ventricular fibrillation arrest or cardiogenic shock were included, and patients with concurrent ST-segment elevation myocardial infarction (n=68) received cardiac intervention and cooling simultaneously. Overall survival to hospital discharge was 56%, and 92% of survivors were discharged with a positive neurological outcome. Survival was similar in transferred and nontransferred patients. Non–ventricular fibrillation arrest and presence of cardiogenic shock were associated strongly with mortality, but survivors with these event characteristics had high rates of positive neurological recovery (100% and 89%, respectively). A 20% increase in the risk of death (95% confidence interval, 4% to 39%) was observed for every hour of delay to initiation of cooling. Conclusions— A comprehensive TH protocol can be integrated into a regional ST-segment elevation myocardial infarction network and achieves broad dispersion of this essential therapy for OHCA.

Increased survival after EMS witnessed cardiac arrest. Observations from the Resuscitation Outcomes Consortium (ROC) Epistry—Cardiac arrest

Background Out of hospital cardiac arrest (OHCA) is common and lethal. It has been suggested that OHCA witnessed by EMS providers is a predictor of survival because advanced help is immediately available. We examined EMS witnessed OHCA from the Resuscitation Outcomes Consortium (ROC) to determine the effect of EMS witnessed vs. bystander witnessed and unwitnessed OHCA. Methods Data were analyzed from a prospective, population-based cohort study in 10 U.S. and Canadian ROC sites. Individuals with non-traumatic OHCA treated 04/01/06–03/31/07 by EMS providers with defibrillation or chest compressions were included. Cases were grouped into EMS-witnessed, bystander witnessed, and unwitnessed and further stratified for bystander CPR. Multiple logistic regressions evaluated the odds ratio (OR) for survival to discharge relative to the EMS-witnessed group after adjusting for age, sex, public/private location of collapse, ROC site, and initial ECG rhythm. Of 9991 OHCA, 1022 (10.2%) of EMS-witnessed, 3369 (33.7%) bystander witnessed, and 5600 (56.1%) unwitnessed. Results The most common initial rhythm in the EMS-witnessed group was PEA which was higher than in the bystander- and unwitnessed groups ( p < 0.001). The adjusted OR (95% CI) of survival compared to the EMS-witnessed group was 0.41, (0.36, 0.46) in bystander witnessed with bystander CPR, 0.37 (0.33, 0.43) in bystander witnessed without bystander CPR, 0.17 (0.14, 0.20) in unwitnessed with bystander CPR and 0.21 (0.18, 0.24) in unwitnessed cases without bystander CPR. Conclusions Immediate application of prehospital care for OHCA may improve survival. Efforts should be made to educate patients to access 9-1-1 for prodromal symptoms.

Clinical Decision Rules for Termination of Resuscitation in Out-of-Hospital Cardiac Arrest

Background: Out-of-hospital cardiac arrest (OHCA) has a low probability of survival to hospital discharge. Four clinical decision rules (CDRs) have been validated to identify patients with no probability of survival. Three of these rules focus on exclusive prehospital basic life support care for OHCA, and two of these rules focus on prehospital advanced life support care for OHCA. Clinical Question: Can a CDR for the termination of resuscitation identify a patient with no probability of survival in the setting of OHCA? Evidence Review: Six validation studies were selected from a PubMed search. A structured review of each of the studies is presented. Results: In OHCA receiving basic life support care, the BLS-TOR (basic life support termination of resuscitation) rule has a positive predictive value for death of 99.5% (95% confidence interval 98.9–99.8%), and decreases the transportation of all patients by 62.6%. This rule has been appropriately validated for widespread use. In OHCA receiving advanced life support care, no current rule has been appropriately validated for widespread use. Conclusions: The BLS-TOR rule is a simple rule that identifies patients who will not survive OHCA. Further research is required to identify similarly robust CDRs for patients receiving advanced life support care in the setting of OHCA.