Regional cardiac resuscitation systems of care

Out-of-hospital cardiac arrest (OOHCA) is a common public health problem, with large and important regional variations in outcomes. Survival rates vary widely among patients treated with OOHCA by emergency medical services (EMS), or among patients transported to the hospital after return of spontaneous circulation. Most regions lack a well-coordinated approach to post–cardiac arrest care. Effective hospital-based interventions for OOHCA exist but are used infrequently. Increased volume of patients or procedures of individual providers and hospitals is associated with better outcomes for several other clinical disorders. Regional systems of cardiac resuscitation include a process for identification of patients with OOHCA, standard field and hospital care protocols for patients with OOHCA, monitoring of care processes and out-come, and periodic review and feedback of these quality improvement data to identify problems and implement solutions. Similar systems have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. Many more people could survive OOHCA if regional systems of cardiac resuscitation were implemented and maintained. The time has come to do so wherever feasible. 

out-of-hospital cardiac arrest, emergency medical serv-ices, hospital-based interventions, regional systems of cardiopulmo-nary resuscitation (CPR), monitoring, outcome, transport time, improve of quality, survival

1. Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 2008; 300(12):1423-31.

2. Atwood C, Eisenberg MS, Herlitz J, Rea TD. Incidence of EMS-treated out-of-hospital cardiac arrest in Europe. Resuscitation 2005;67(1):75-80.

3. Herlitz J, Engdahl J, Svensson L, Angquist KA, Silfverstolpe J, Holmberg S. Major differences in 1-month survival between hospitals in Sweden among initial survivors of out-of-hospital cardiac arrest. Resuscitation 2006;70(3):404-9.

4. Carr BG, Kahn JM, Merchant RM, Kramer AA, Neumar RW. Inter-hospital variability in post-cardiac arrest mortality. Resuscitation 2009;80(1):30-4.

5. Liu JM, Yang Q, Pirrallo RG, Klein JP, Aufderheide TP. Hospital variability of out-of-hospital cardiac arrest survival. Prehosp Emerg Care 2008;12(3):339-46.

6. Rea TD, Cook AJ, Stiell IG, Powell J, Bigham B, Callaway CW, et al. Predicting Survival After Out-of-Hospital Cardiac Arrest: Role of the Utstein Data Elements. Ann Emerg Med 2010;55:249-57.

7. Rea TD, Eisenberg MS, Becker LJ, Murray JA, Hearne T. Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective. Circulation 2003;107(22):2780-5.

8. Iwami T, Nichol G, Hiraide A, Hayashi Y, Nishiuchi T, Kajino K, et al. Continuous improvements in “Chain of Survival” increased survival after out-of-hospital cardiac arrests: a large-scale population-based study. Circulation 2009;119(5):728-34.

9. Herlitz J, Bang A, Gunnarsson J, Engdahl J, Karlson BW, Lindqvist J, et al. Factors associated with survival to hospital discharge among patients hospitalised alive after out of hospital cardiac arrest: change in outcome over 20 years in the community of Goteborg, Sweden. Heart 2003;89(1):25-30.

10. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354(4):366-78.

11. Jacobs AK. Regional systems of care for patients with ST-elevation myocardial infarction: being at the right place at the right time. Circula-tion 2007;116(7):689-92.

12. Henry TD, Sharkey SW, Burke MN, Chavez IJ, Graham KJ, Henry CR, et al. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation 2007;116(7):721-8.

13. Ting HH, Rihal CS, Gersh BJ, Haro LH, Bjerke CM, Lennon RJ, et al. Regional systems of care to optimize timeliness of reperfusion therapy for ST-elevation myocardial infarction: the Mayo Clinic STEMI Protocol. Circulation 2007;116(7):729-36.

14. Nichol G, Aufderheide TP, Eigel B, Neumar RW, Lurie KG, Bufalino VJ, et al. Regional Systems of Care for Out-of-Hospital Cardiac Arrest: A Policy Statement From the American Heart Association. Circulation 2010;In Press.

15. Siegel D. The gap between knowledge and practice in the treatment and prevention of cardiovascular disease. Prev Cardiol 2000;3(4):167-71.

16. Hartocollis A. City pushes cooling therapy for cardiac arrest New York Times. New York Times December 4,2008;A1.

17. Spector H. MetroHealth, Cleveland EMS don’t back regional approach for cardiac arrest therapy. MetroHealth, EMS: not enough evidence to alter treatment. Plain Dealer. Published online March 23, 2009 (cited 2010 July 25). Available: http://www.cleveland.com/medical/plain-dealer/index.ssf?/base/news/123779719327900.xml&coll=2. Accessed January 5, 2010.

18. Davis DP, Fisher R, Aguilar S, Metz M, Ochs G, McCallum-Brown L, et al. The feasibility of a regional cardiac arrest receiving system. Resuscitation 2007;74(1):44-51.

19. Spaite DW, Stiell IG, Bobrow BJ, de Boer M, Maloney J, Denninghoff K, et al. Effect of transport interval on out-of-hospital cardiac arrest survival in the OPALS study: implications for triaging patients to specialized cardiac arrest centers. Ann Emerg Med 2009;54(2):248-55.

20. Spaite DW, Bobrow BJ, Vadeboncoeur TF, Chikani V, Clark L, Mullins T, et al. The impact of prehospital transport interval on survival in out-of-hospital cardiac arrest: implications for regionalization of post-resuscitation care. Resuscitation 2008;79(1):61-6.

21. Cudnik MT, Schmicker RH, Vaillancourt C, Newgard CD, Christenson JM, Davis DP, et al. A geospatial assessment of transport distance and survival to discharge in out of hospital cardiac arrest patients: Implications for resuscitation centers. Resuscitation 2010;81(5):518-23.

22. Kajino K. Impact of transport to critical care medical centers on outcomes after out-of-hospital cardiac arrest. Resuscitation. 2010;In Press.

23. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349(22):2117-27.

24. Carr BG, Goyal M, Band RA, Gaieski DF, Abella BS, Merchant RM, et al. A national analysis of the relationship between hospital factors and post-cardiac arrest mortality. Intensive Care Med 35(3):505-11.

25. Nathens AB, Jurkovich GJ, Maier RV, Grossman DC, MacKenzie EJ, Moore M, et al. Relationship between trauma center volume and outcomes. JAMA 2001;285(9):1164-71.

26. Canto JG, Every NR, Magid DJ, Rogers WJ, Malmgren JA, Frederick PD, et al. The volume of primary angioplasty procedures and survival after acute myocardial infarction. The National Registry of Myocardial Infarction 2 Investigators. N Engl J Med 2000;342(21):1573-80.

27. Kahn JM, Goss CH, Heagerty PJ, Kramer AA, O’Brien CR, Rubenfeld GD. Hospital volume and the outcomes of mechanical ventilation. N Engl J Med 2006;355(1):41-50.

28. Callaway CW, Schmicker RH, Kampmeyer M, Powell J, Nichol G, Rea TD, et al. Influence of Receiving Hospital Characteristics on Survival after Cardiac Arrest [Abstract]. Circulation 2008;118(S):1446.

29. Nichol G, Aufderheide TP, Eigel B, Neumar RW, Lurie KG, Bufalino VJ, et al. Regional systems of care for out-of-hospital cardiac arrest: A policy statement from the American Heart Association. Circulation 2010;121(5):709-29.

30. Dalby M, Bouzamondo A, Lechat P, Montalescot G. Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: a meta-analysis. Circulation 2003;108(15):1809-14.

31. Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007 focused update of the ACC/AHA 2004 Guide-lines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Canadian Cardiovascular Society, endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, writing on behalf of the 2004 Writing Committee. Circulation 2008;117(2):296-329.

32. Mongan JJ, Ferris TG, Lee TH. Options for slowing the growth of health care costs. N Engl J Med 2008;358(14):1509-14.

33. Frandsen F, Nielsen JR, Gram L, Larsen CF, Jorgensen HRI, Hole P, et al. Evaluation of intensified prehospital treatment in out-of-hospital cardiac arrest: survival and cerebral prognosis. The Odense Ambulance Study. Cardiology 1991;79:256-64.

34. Bergner L, Bergner M, Hallstrom AP, Eisenberg MS, Cobb LA. Service factors and health status of survivors of out-of-hospital cardiac arrest. Am J Emerg Med 1983;1(3):259-63.

35. Nichol G, Stiell IG, Hebert P, Wells GA, Vandemheen K, Laupacis A. What is the quality of life of survivors of cardiac arrest? A prospective study. Acad Emerg Med 1999;6:95-102.

36. Nichol G, Huszti E, Birnbaum A, Mahoney B, Weisfeldt M, Travers A, et al. Cost-effectiveness of lay responder defibrillation for out-of-hospital cardiac arrest. Ann Emerg Med 2009;In Press.

37. Committee on the Future of Emergency Care in the United States. Emergency Medical Services: At the Crossroads. Washington, DC: Institute of Medicine/National Academies Press2006.

38. US Trauma Center Crisis: Lost in the Scramble for Terror Resources. Irvine, CA: National Foundation for Trauma Care; 2004.

39. Fisher A, Ross C, Henderson C, Kirk S, Feroze M, Richmond R, et al. Major Trauma Care in England. London: National Audit Office 2010.

40. Committee on the Future of Emergency Care in the United States. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: Institute of Medicine/National Academies Press; 2006.

41. Lewin ME, Altman S. America’s Health Care Safety Net: Intact but Endangered. Washington, DC: Institute of Medicine 2000.

42. Committee on the Future of Emergency Care in the United States Health System Board on Health Care Services. Emergency Medical Services At the Crossroads. Washington, DC: Institute of Medicine, National Academy of Science 2006.