Direct Transport to a Percutaneous Cardiac Intervention Center and Outcomes in Patients With Out-of-Hospital Cardiac Arrest

Abstract

O ut-of-hospital cardiac arrest (OHCA) is a major public healthcare issue affecting 200 000 to 400 000 Americans each year, with large variations in incidence, resuscitation practice, and outcomes between communities.1,2 Regional systems of care involving centralization of postresuscitation care have been proposed to improve outcomes because multiple organ systems can be affected after OHCA that likely are best treated at regional centers with percutaneous cardiac intervention (PCI) and critical care capabilities. [3][4][5][6] There is consensus that a regional cardiac arrest center at a minimum must have (1) a cardiac catheterization laboratory that is immediately accessible 24/7 and (2) the capability to provide targeted temperature management (TTM). Background-Practice guidelines recommend regional systems of care for out-of-hospital cardiac arrest. However, whether emergency medical services should bypass nonpercutaneous cardiac intervention (non-PCI) facilities and transport outof-hospital cardiac arrest patients directly to PCI centers despite longer transport time remains unknown. Methods and Results-Using the Cardiac Arrest Registry to Enhance Survival with geocoding of arrest location, we identified out-of-hospital cardiac arrest patients with prehospital return of spontaneous circulation and evaluated the association between direct transport to a PCI center and outcomes in North Carolina during 2012 to 2014. Destination hospital was classified according to PCI center status (catheterization laboratory immediately accessible 24/7). Inverse probability-weighted logistic regression accounting for age, sex, emergency medical services response time, clustering of county, transport time to nearest PCI center, initial heart rhythm, and prehospital ECG information was performed. Of 1507 patients with prehospital return of spontaneous circulation, 1359 (90.2%) were transported to PCI centers, of whom 873 (57.9%) bypassed the nearest non-PCI hospital and 148 (9.8%) were transported to non-PCI hospitals. Discharge survival was higher among those transported to PCI centers (33.5% versus 14.6%; adjusted odds ratio, 2.47; 95% confidence interval, 2.08-2.92). Compared with patients taken to non-PCI hospitals, odds of survival were higher for patients taken to the nearest hospital with PCI center status (odds ratio, 3.07; 95% confidence interval, 1.90-4.97) and for patients bypassing closer hospitals to PCI centers (odds ratio, 3.02; 95% confidence interval, 2.01-4.53). Adjusted survival remained significantly better across transport times of 1 to 5, 6 to 10, 11 to 20, 21 to 30, and >30 minutes. Conclusions-Direct transport to a PCI center is associated with better outcomes for out-of-hospital cardiac arrest patients, even when bypassing nearest hospital and regardless of transport time. (Circ Cardiovasc Qual Outcomes.

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

“…Using a mathematical model, Kragholm, et al concluded that there is survival benefit for cardiac arrest patients with prehospital ROSC to be transported to CAC even if journey time exceeds 20 minutes. [46] Similar findings were reported by Tranberg et al who also reported that distances from arrest location to CAC was not associated with patient survival. [43] In contrast, regression analyses from Cournoyer study stated that increasing the delay from call to hospital arrival by 14.0 min would offset the potential survival benefit of being transported to a PCI-capable centre.…”

“…Survival to hospital discharge was reported in ten studies (three retrospective cohort studies and two before and after studies with adjusted analyses, and five retrospective analyses with unadjusted analyses) including 42780 patients. [38][39][40][45][46][47][48][49][50] Data from meta-analysis of 5 studies (n=11,662)…”

“…These replacements made no difference to our overall findings (data not shown). We performed sensitivity analyses to explore the source of heterogeneity by firstly excluding data from studies that transported only patients with pre-hospital ROSC [38,40,45,46] for two outcomes: Survival to hospital discharge with favourable outcomes (2 studies) and Survival to hospital discharge (4 studies). This did not change our overall findings but did reduce statistical heterogeneity in Survival to hospital discharge from I 2 90% to 52% (data not shown).…”

“…We encountered high statistical heterogeneity in our meta-analysis and scrutinised included study characteristics for potential source of bias. Four studies [38,40,45,46] included only patients with…”

Association of acute myocardial infarction cardiac arrest patient volume and in‐hospital mortality in the United States: Insights from the National Cardiovascular Data Registry Acute Coronary Treatment And Intervention Outcomes Network Registry

“…The ACC and American Heart Association and currently recommend regionalized patient care for patients resuscitated from out‐of‐hospital cardiac arrest at hospitals that are designated as cardiac resuscitation centers. Prior studies have demonstrated that regionalization of care for cardiac arrest patients has improved outcomes, whether done at the city or state level.…”