Coordinated, regional care will help improve outcomes for individuals who suffer an out-of-hospital cardiac arrest, according to a policy statement from the American Heart Association.
Similar regional systems have been successful for treating ST-elevation myocardial infarction and life-threatening trauma, according to the authors, led by Graham Nichol, MD, MPH, of the University of Washington in Seattle.
“The time has come to develop and implement regional systems of care for patients resuscitated from out-of-hospital cardiac arrest to try to achieve similar improvements in outcomes,” they wrote online in Circulation: Journal of the American Heart Association.
Nichol and the other group members said integrating care at each step of the process — from resuscitation by emergency medical services teams, to triage at referral hospitals, to arrival at receiving centers specializing in postcardiac arrest care — would improve survival to discharge.
The median survival-to-discharge following EMS-treated, out-of-hospital cardiac arrest in North America is just 8.4%.
But in areas with regional care systems, survival is much better. In Seattle, for example, the survival rate after any initial rhythm was 16.3%, and it reached nearly 40% after arrests caused by ventricular fibrillation.
Unfortunately, the authors asserted, most regions lack this coordinated approach, with barriers that include lack of experience, knowledge about effective interventions, personnel, resources, and infrastructure.
“The time to implement these systems of care is now,” they wrote.
Nichol and his colleagues noted that guidelines for improving care for victims of out-of-hospital cardiac arrest have been released, but they said uptake has been slow.
For example, they noted, therapeutic hypothermia after patients reach the hospital has been shown to improve outcomes, but the practice is applied infrequently.
Also, postresuscitation care should include percutaneous coronary intervention when ischemia is suspected, early hemodynamic stabilization, a reliable prediction of long-term outcome, and an evaluation of the need for an implantable cardioverter-defibrillator before discharge.
“ICDs decrease mortality rates in survivors of cardiac arrest with good neurological recovery when treatable causes of arrest are not determined, in patients with underlying coronary disease without myocardial ischemia as the cause of arrest, and in patients with a low ejection fraction (i.e., <30% to 35%) in combination with medical therapy,” the authors wrote.
Regional systems of care will better enable the administration of care according to evidence-based guidelines, they said.
“As with trauma centers, burn centers, STEMI centers, and stroke centers, national criteria should be developed to enable the categorization, verification, and designation of centers for the treatment of patients with restoration of circulation after out-of-hospital cardiac arrest,” they wrote.
They said specialized care centers, limited in number to ensure sufficient volumes of patients and keep costs down, should be certified by an external agency.
“Some may argue that the costs or charges associated with this multifaceted approach are likely to be excessive,” the authors added, “but resuscitation interventions that are associated with increased rates of survival are also associated with improved quality of life and acceptable cost to society.”
They asserted that the additional funding needed to establish these systems could be achieved through shared reimbursement for care among various levels of the system, from EMS to the centers specializing in postcardiac arrest care.
Nichol reported receiving research grants from the NIH, the Asmund S. Laerdal Foundation for Acute Medicine, and the National Heart, Lung, and Blood Institute.
He also reported relationships with the Canadian Institutes of Health Research, Medtronic, the U.S. Department of Defense, the Heart and Stroke Foundation of Canada, Laerdal, Physio-Control, and Channing Bete.
The other members of the writing group reported relationships with numerous pharmaceutical and medical device companies.