Prognostic Implications of Level-of-Care at Tertiary Heart Centers Compared With Other Hospitals After Resuscitation From Out-of-Hospital Cardiac Arrest (original) (raw)
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Receiving hospital characteristics associated with survival after out-of-hospital cardiac arrest
Resuscitation, 2010
Aim-Survival after out-of-hospital cardiac arrest (OOHCA) varies between regions, but the contribution of different factors to this variability is unknown. This study examined whether survival to hospital discharge was related to receiving hospital characteristics, including bed number, capability of performing cardiac catheterization and hospital volume of OOHCA cases.
The Hospital's Role in Improving Survival of Patients With Out-of-Hospital Cardiac Arrest
Clinical Cardiology, 2012
Out-of-hospital cardiac arrest (OHCA) is a major public health problem. Unfortunately, in spite of recurring updated guidelines, survival of patients with OHCA had been unchanged for decades. Recently, new approaches to patients with OHCA during the community and prehospital phases of therapy for cardiac arrest have resulted in a dramatic improvement in survival. Further improvement in survival has resulted from hospitals designated as Cardiac Receiving Centers. These centers are committed to the treatment of post-cardiac arrest syndrome by providing 24/7 therapeutic mild hypothermia, urgent cardiac catheterization and percutaneous coronary intervention, evidence-based termination of resuscitation protocols that limit premature withdrawal of care, protocol to address organ donation, commitment of cardiocerebral resuscitation training in their community, and a commitment and proven ability of data collection to assure that instituted changes result in improved survival. This newer aspect of hospital practice is an aspect that needs to be embraced by either becoming a Cardiac Receiving Center or partnering with other hospitals that can provide this critically important service.
The American Journal of Cardiology, 2015
Despite advances in cardiopulmonary resuscitation (CPR), survival remains low after out-of-hospital cardiac arrest (OOHCA). Acute coronary ischemia is the predominating precipitant, and prompt delivery of patients to dedicated facilities may improve outcomes. Since 2011, all patients experiencing OOHCA in London, where a cardiac etiology is suspected, are systematically brought to heart attack centers (HACs). We determined the predictors for survival and favorable functional outcomes in this setting. We analyzed 174 consecutive patients experiencing OOHCA from 2011 to 2013 brought to Harefield Hospital-a designated HAC in London. We analyzed (1) all-cause mortality and (2) functional status using a modified Rankin scale (mRS 0 to 6, where mRS0-3 D [ favorable functional status). The overall survival rates were 66.7% (30 days) and 62.1% (1 year); and 54.5% had mRS0-3 D at discharge. Patients with mRS0-3 D had reduced mortality compared to mRS0-3 L : 30 days (1.2% vs 72.2%, p <0.001) and 1 year (5.3% vs 77.2%, p <0.001). Multivariate analyses identified lower patient comorbidity, absence of cardiogenic shock, bystander CPR, ventricular tachycardia/ ventricullar fibrillation as initial rhythm, shorter duration of resuscitation, prehospital advanced airway, absence of adrenaline and inotrope use, and intra-aortic balloon pump use as predictors of mRS0-3 D. Consistent predictors of increased mortality were the presence of cardiogenic shock, advanced airway use, increased duration of resuscitation, and absence of therapeutic hypothermia. A streamlined delivery of patients experiencing OOHCA to dedicated facilities is associated with improved functional status and survival. Our study supports the standardization of care for such patients with the widespread adoption of HACs. Ó 2015 Elsevier Inc. All rights reserved. (Am J Cardiol 2015;115:730e737) The incidence of out-of-hospital cardiac arrests (OOH-CAs) is approximately 60,000 in the United Kingdom and 420,000 in the United States each year. 1,2 Coronary artery disease is responsible for >70% of OOHCA, 3 and rapid access to cardiac catheterization may improve outcomes in these patients. 3e7 Since 2011, the London Ambulance Service (LAS) embarked on a pathway enabling ambulance personnel to bypass the nearest hospital and transfer patients with OOHCA, if the cause was considered primarily cardiac, directly to 1 of 8 heart attack centers (HACs) for immediate cardiac catheterization and revascularization, if indicated. This has led to a significant increase in survival rate-discharge survival rates for those meeting the Utstein comparator criteria increased from 12% in 2007 to 32% in 2012. 7,8 Randomized studies are often difficult in patients with OOHCA, and our understanding in this field is largely driven by observational data. Although many observational studies have documented predictors of outcomes in these patients, there are no studies specifically examining the outcomes where patients experiencing OOHCA undergo a prehospital triaging system and strategic delivery to dedicated HACs, particularly over a contemporary period. Thus, we analyzed the predictors of favorable functional status and survival in patients experiencing OOHCA in this setting. Methods This was an observational analysis to determine the predictors of favorable functional status at discharge and longterm survival in 182 consecutive patients experiencing an OOHCA from 2011 to 2013 who were brought directly by the emergency medical services (EMS) to Harefield Hospital, Middlesex-1 of 8 designated heart attack centers in London. Of these, return of spontaneous circulation was achieved in 174 patients (96%) and included in the final analysis. The LAS is the largest free emergency medical ambulance service in the
Resuscitation, 2012
Background: Resuscitation centers may improve patient outcomes by achieving sufficient experience in post-resuscitation care. We analyzed the relationship between survival and hospital volume among patients suffering out-of-hospital cardiac arrest (OHCA). Methods: This prospective cohort investigation collected data from the Cardiac Arrest Registry to Enhance Survival database from 10/1/05 to 12/31/09. Primary outcome was survival to discharge. Hospital characteristics were obtained via 2005 American Hospital Association Survey. A hospital's use of hypothermia was obtained via direct survey. To adjust for hospital-and patient-level variation, multilevel, hierarchical logistic regression was performed. Hospital volume was modeled as a categorical (OHCA/year ≤ 10, 11-39, ≥40) variable. A stratified analysis evaluating those with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) was also performed. Results: The cohort included 4125 patients transported by EMS to 155 hospitals in 16 states. Overall survival to hospital discharge was 35% among those admitted to the hospital. Individual hospital rates of survival varied widely (0-100%). Unadjusted survival did not differ between the 3 hospital groups (36% for ≤10 OHCA/year, 35% for 11-39, and 36% for ≥40; p = 0.75). After multilevel adjustment, differences in survival across the groups were not statistically significant. Compared to patients at hospitals with ≤10 OHCA/year, adjusted OR for survival was 1.04 (CI 95 0.83-1.28) among 11-39 annual volume and 0.97 (CI 95 0.73-1.30) among the ≥40 volume hospitals. Among patients presenting with VF/VT, no difference in survival was identified between the hospital groups. Conclusion: Survival varied substantially across hospitals. However, hospital OHCA volume was not associated with likelihood of survival. Additional efforts are required to determine what hospital characteristics might account for the variability observed in OHCA hospital outcomes.
2013
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.
BioMed Research International
Background. Mortality of admitted out-of-hospital cardiac arrest (OHCA) patients is decreasing. Our aim was to evaluate independent predictors of six-month mortality of successfully resuscitated OHCA patients. Methods. We reviewed retrospectively the records of 119 OHCA patients, admitted in 2011 to 2013 (73.1% men, mean age 64 ± 13,5 years) and registered their clinical data, treatments, and predictors of 6-month mortality. Results. Six-month mortality of admitted OHCA patients was 47.5% and was associated significantly with older age (67.7 ± 12.9 years versus 59.9 ± 13 years, p<0.05), mechanical ventilation, longer time of resuscitation (24.6 ± 18.9 sec versus 8.9 ± 8.4 sec, p<0.05), use of vasopressors (87.3% versus 62.5%, p<0.05), and increased serum lactate (8.1 ± 3.9 mmol/l versus 4.5 ± 3.6 mmol/l, p<0.05) but less likely with prior shockable rhythm (38% versus 73.2%, p<0.05), percutaneous coronary intervention (27% versus 55.4%, p<0.05), achieved target temp...
Revista Española de Cardiología (English Edition), 2013
Introduction and objectives: Survivors of out-of-hospital cardiac arrest constitute an increasing patient population in cardiac intensive care units. Our aim was to characterize these patients and determine their vital and functional prognosis in accordance with the latest evidence. Methods: A multicenter, prospective register was constructed with information from patients admitted to 5 cardiac intensive care units from January 2010 through January 2012 with a diagnosis of resuscitated out-of-hospital cardiac arrest. The information included clinical status, cardiac arrest characteristics, in-hospital course, and vital and neurologic status at discharge and at 6 months. Results: A total of 204 patients were included. In 64% of cases, a first shockable rhythm was identified. The time to return of spontaneous circulation was 29 (18) min. An etiologic diagnosis was made in 86% of patients; 44% were discharged with no neurologic sequelae; 40% died in the hospital. At 6 months, 79% of survivors at discharge were still alive and neurologically intact with minimal sequelae. Short resuscitation time, first recorded rhythm, pH on admission >7.1, absence of shock, and use of hypothermia were the independent variables associated with a good neurologic prognosis. Conclusions: Half the patients who recovered from out-of-hospital cardiac arrest had good neurologic prognosis at discharge, and 79% of survivors were alive and neurologically intact after 6 months of follow-up.
Resuscitation, 2010
Background: Survival after out-of-hospital cardiac arrest (OHCA) depends on a well functioning Chain of Survival. We wanted to assess if targeted attempts to strengthen the weak links of our local chain; quality of advanced life support (ALS) and post-resuscitation care, would improve outcome. Materials and methods: Utstein data from all OHCAs in Oslo during three distinct 2-year time periods 1996-1998, 2001-2003 and 2004-2005 were collected. Before the second period the local ALS guidelines changed with increased focus on good quality chest compressions with minimal pauses, while standardized post-resuscitation care including goal directed therapy with therapeutic hypothermia and percutaneous coronary intervention was added in the third period. Additional a priori subgroup analyses of arrests with cardiac aetiology as well as bystander witnessed ventricular fibrillation/tachycardia (VF/VT) arrests with cardiac aetiology were performed. Results: ALS was attempted in 454, 449, and 417 patients with OHCA in the first, second and last time period, respectively. From the first to the third period VF/VT arrests declined (40% vs. 33%, p = 0.039) and fewer arrests were witnessed (80% vs. 72%, p = 0.022) and response intervals increased (7 ± 4 to 9 ± 4 min, p < 0.001). Overall survival increased from 7% (first period) to 13% (last period), p = 0.002, and survival in the subgroup of bystander witnessed VF/VT arrests with cardiac aetiology increased from 15% (first period) to 35% (last period), p = 0.001. Conclusions: Survival after OHCA was increased after improving weak links of our local Chain of Survival, quality of ALS and post-resuscitation care.
Location of out-of-hospital cardiac arrest as a determinant in the survival of patients
Srpski arhiv za celokupno lekarstvo, 2016
Introduction Cardiac arrest (CA) is defined as a sudden cessation of normal circulation of blood due to failure of the heart to contract effectively during systole. Objective The aim of this study was to determine the difference in outcome among patients, depending on the location of out-of-hospital CA; to determine the influence of observed determinants on the survival rate. Methods Observational and retrospective study was conducted in the Institute for Emergency Medical Service Novi Sad (IEMS NS). It included patients who underwent cardiopulmonary resuscitation (CPR) by medical ambulance squads. Patients were divided into three groups, based on the location of CA: private place, public place, and medical institution. Results CA occurred in private places in 151 cases (76.26%). The shortest duration of a phone call with the dispatcher and Reaction Time I was in the group of patients with CA in a public place (59.1 ± 36.4 seconds and 137.1 ± 89.8 seconds, respectively). CA was recognized in more than 80% of cases, but CPR was initiated in only 9.09% of patients in private places and in 19.35% of patients in public places. Though they initially presented with shockable rhythm in 57.14% of cases in public places, this group has the worst immediate outcome (11.43%), in contrast to the patients with CA in medical institutions (58.33%). Factors determining the survival of patients with CA were CPR attempted immediately after collapse, initial rhythm and eyewitnesses of CA. Conclusion In order to improve survival of patients with out-of-hospital CA, both education of laymen and introduction of standard questioning protocol in the IEMS Call Centre are necessary.