Therapeutic Hypothermia for Patients with Out-of-Hospital Cardiac Arrest in North Carolina.

INTRODUCTION: While therapeutic hypothermia has been the standard of care for patients who suffer out-of-hospital cardiac arrest (OHCA), recent trials have led to an advisory statement recommending a focus on targeted in-hospital temperature management and against initiation of prehospital hypothermia with rapid infusion of cooled saline. The aim of this study is to review the experience with therapeutic hypothermia in North Carolina. METHODS: We studied patients who suffered OHCA in North Carolina in 2012 captured in the CARES database as part of the Heart Rescue Project. We excluded patients without return of spontaneous circulation and patients without an advanced airway placed in the field to reduce selection bias. Bivariate distributions and multivariate logistic regression models were used to examine differences in survival to discharge and positive neurological outcome. RESULTS: 847 patients were included in the analysis of pre-hospital hypothermia. Of these patients, 55% received prehospital hypothermia. Prehospital initiation of hypothermia was associated with higher survival to hospital discharge (OR 1.55, 95% CI 1.03-2.32) and improved neurologic outcome at discharge (OR 1.56 95% CI 1.01-2.40). In patients who survived to hospital admission (n = 537), in-hospital hypothermia was associated with a non-significant trend toward better survival to discharge (p = 0.18). CONCLUSION: We found that patients who received prehospital hypothermia had improved outcomes, a finding that may be due to a greater likelihood of receiving in-hospital hypothermia or a reflection of higher quality of pre-hospital care. These findings support ongoing efforts to improve all aspects of the chain of survival after cardiac arrest.

Early neurologic examination is not reliable for prognostication in post-cardiac arrest patients who undergo therapeutic hypothermia.

BACKGROUND: Recent advances in post-cardiac arrest (CA) care including therapeutic hypothermia (TH) have improved survival and favorable neurologic outcomes for survivors of CA. Survivors often present with deep coma and lack of brainstem reflexes, which are generally associated with adverse outcomes in many disease processes. Little is known regarding the role of initial emergency department (ED) neurological examination and its potential for prognostication. OBJECTIVES: The purpose of this study is to determine if components of a standardized neurologic examination are reliable prognosticators in patients recently resuscitated from CA. We hypothesize that lack of neurologic function does not reliably predict an adverse outcome and, therefore, should not be used to determine eligibility for TH. METHODS: A standardized neurologic examination was performed in the ED on a prospective, convenience cohort of post-CA patients presenting to a CA resuscitation center who would undergo a comprehensive postarrest care pathway that included TH. Data such as prior sedation or active neuromuscular blockade were documented to evaluate for the presence of possible confounders. Examination findings were then compared with hospital survival and neurologic outcome at discharge as defined by the cerebral performance category (CPC) score as documented in the institutional TH registry. RESULTS: Forty-nine subjects were enrolled, most of whom presented comatose with a Glasgow Coma Scale of 3 (n=41, 83.7%). Nineteen subjects (38.8%) had absence of all examination findings, of which 4 of 19 (21.1%) survived to hospital discharge. Of those with at least 1 positive examination finding, 13 of 30 subjects (43.3%) survived to hospital discharge. Subgroup analysis showed that 9 of the 19 patients with absence of brainstem reflexes did not have evidence of active neuromuscular blockade at the time of the examination; 2 of 9 (22.1%) survived to hospital discharge. Eight of these subjects in this group had not received any prior sedation; 1 of 8 (12.5%) survived to hospital discharge. Only 1 of the 17 subjects who survived was discharged with poor neurologic function with a CPC score=3, whereas all others who survived had good neurologic function, CPC score=1. CONCLUSION: In this cohort of patients treated in a comprehensive postarrest care pathway that included TH, absence of neurologic function on initial ED presentation was not reliable for prognostication. Given these findings, clinicians should refrain from using the initial ED neurological examination to guide the aggressiveness of care or in counseling of family members regarding anticipated outcome.

Cardiac arrest with initial arrest rhythm of pulseless electrical activity: do rhythm characteristics correlate with outcome?

OBJECTIVES: Cardiac arrest is a leading cause of death in the United States, with pulseless electrical activity (PEA) as a common initial arrest rhythm. We sought to determine if rate of electrical activity and QRS width correlate with survival in patients who present with PEA out-of-hospital cardiac arrest. METHODS AND RESULTS: This is a retrospective review of patients with PEA out-of-hospital cardiac arrest with first documented cardiac rhythm of PEA from January 2010 to September 2013. Demographic, arrest and initial rhythm characteristics, and patient outcome were abstracted via systematic chart review. The initial 20 seconds of each rhythm strip were used to ascertain electrical rate and QRS width. Primary outcome was survival to hospital discharge. Four hundred fourteen patients were eligible for the study. One hundred fifty-two patients did not have sufficient data for analysis. Two hundred sixty-two patients were included in the final analysis with mean age, 66 years. There were 23 (8.8%) survivors and 17 (6.5%) neurologically intact survivors. Mean heart rate was 58 (confidence interval, 54-63) beats per minute, and mean QRS interval was 100 (confidence interval, 95-106) milliseconds. Twenty-nine point seven percent of patients had wide QRS complexes, and 70.3% were narrow. There was no difference in survival in patients based on heart rate (13.1% vs 7.4%, P = .16) or QRS interval (8.7% vs 7.7%, P = .79). CONCLUSIONS: In this single emergency medical services agency study, neither PEA electrical rate nor QRS width correlated with survival or neurologic outcome.

ED prognostication of comatose cardiac arrest patients undergoing therapeutic hypothermia is unreliable.

BACKGROUND: Therapeutic hypothermia (TH) improves patient survival with good neurologic outcome after cardiac arrest. The value of early clinician prognostication in the emergency department (ED) has not been studied in this patient population. OBJECTIVE: To determine if physicians can accurately predict survival and neurologic outcome at hospital discharge of resuscitated, comatose out-of-hospital cardiac arrest (OHCA) patients treated in a post-cardiac arrest clinical pathway that included TH. METHODS: This was a prospective, observational study conducted at a tertiary referral center. Participants were physicians involved in the resuscitation of OHCA patients treated with a clinical pathway that included TH. Immediately after patient resuscitation in the ED, physicians recorded their prediction of patient survival and neurologic outcome on a standardized questionnaire. Neurologic outcome was assessed by the cerebral performance category. RESULTS: Forty-two physicians completed questionnaires on 17 patients enrolled from October 2009 to March 2010. Sensitivity and specificity of physician prediction of patient survival were 0.67 (95% confidence interval [CI], 0.45-0.83) and 0.82 (95% CI, 0.59-0.94), respectively, with an area under the curve of 0.74 (95% CI, 0.61-0.88), a positive likelihood ratio (+LR) of 3.72 (95% CI, 1.30-11.02), and a -LR of 0.40 (95% CI, 0.21-0.77). Sensitivity and specificity of physician prediction of good neurologic outcome were 0.40 (95% CI, 0.20-0.64) and 0.69 (95% CI, 0.50-0.84), respectively, with an area under the curve of 0.55 (95% CI, 0.39-0.70), a +LR of 1.29 (95% CI, 0.56-3.03), and a -LR of 0.87 (95% CI, 0.53-1.41). CONCLUSIONS: Physicians poorly prognosticate both survival and neurologic outcome in comatose OHCA patients undergoing TH. Premature prognostication in the ED is unreliable and should be avoided.

Major hemorrhage from hepatic laceration after cardiopulmonary resuscitation.

Visceral injury from cardiac arrest resuscitation is a rare but potentially life-threatening complication. We describe and review 2 cases of hepatic laceration complicated by major abdominal hemorrhage manifested as delayed shock following cardiopulmonary resuscitation after cardiac arrest. Two patients enrolled in our institutional post cardiac arrest resuscitation clinical pathway had evidence of major liver laceration presenting as delayed shock due to massive hemoperitoneum. Case analysis revealed coagulopathy due to systemic anticoagulation as a risk factor for major hemorrhage. Both cases were successfully managed via hepatic artery embolization. Visceral abdominal injuries are an uncommon but important complication of cardiopulmonary resuscitation.Coagulopathy, including therapeutic systemic anticoagulation, is a risk factor for clinically significant hemorrhage.

Association of Bystander and First-Responder Intervention With Survival After Out-of-Hospital Cardiac Arrest in North Carolina, 2010-2013.

IMPORTANCE: Out-of-hospital cardiac arrest is associated with low survival, but early cardiopulmonary resuscitation (CPR) and defibrillation can improve outcomes if more widely adopted. OBJECTIVE: To examine temporal changes in bystander and first-responder resuscitation efforts before arrival of the emergency medical services (EMS) following statewide initiatives to improve bystander and first-responder efforts in North Carolina from 2010-2013 and to examine the association between bystander and first-responder resuscitation efforts and survival and neurological outcome. DESIGN, SETTINGS, AND PARTICIPANTS: We studied 4961 patients with out-of-hospital cardiac arrest for whom resuscitation was attempted and who were identified through the Cardiac Arrest Registry to Enhance Survival (2010-2013). First responders were dispatched police officers, firefighters, rescue squad, or life-saving crew trained to perform basic life support until arrival of the EMS. EXPOSURES: Statewide initiatives to improve bystander and first-responder interventions included training members of the general population in CPR and in use of automated external defibrillators (AEDs), training first responders in team-based CPR including AED use and high-performance CPR, and training dispatch centers in recognition of cardiac arrest. MAIN OUTCOMES AND MEASURES: The proportion of bystander and first-responder resuscitation efforts, including the combination of efforts between bystanders and first responders, from 2010 through 2013 and the association between these resuscitation efforts and survival and neurological outcome. RESULTS: The combination of bystander CPR and first-responder defibrillation increased from 14.1% (51 of 362; 95% CI, 10.9%-18.1%) in 2010 to 23.1% (104 of 451; 95% CI, 19.4%-27.2%) in 2013 (P < .01). Survival with favorable neurological outcome increased from 7.1% (82 of 1149; 95% CI, 5.8%-8.8%) in 2010 to 9.7% (129 of 1334; 95% CI, 8.2%-11.4%) in 2013 (P = .02) and was associated with bystander-initiated CPR. Adjusting for age and sex, bystander and first-responder interventions were associated with higher survival to hospital discharge. Survival following EMS-initiated CPR and defibrillation was 15.2% (30 of 198; 95% CI, 10.8%-20.9%) compared with 33.6% (38 of 113; 95% CI, 25.5%-42.9%) following bystander-initiated CPR and defibrillation (odds ratio [OR], 3.12; 95% CI, 1.78-5.46); 24.2% (83 of 343; 95% CI, 20.0%-29.0%) following bystander CPR and first-responder defibrillation (OR, 1.70; 95% CI, 1.06-2.71); and 25.2% (109 of 432; 95% CI, 21.4%-29.6%) following first-responder CPR and defibrillation (OR, 1.77; 95% CI, 1.13-2.77). CONCLUSIONS AND RELEVANCE: Following a statewide educational intervention on rescusitation training, the proportion of patients receiving bystander-initiated CPR and defibrillation by first responders increased and was associated with greater likelihood of survival. Bystander-initiated CPR was associated with greater likelihood of survival with favorable neurological outcome.

Effectiveness of team-focused CPR on in-hospital CPR quality and outcomes.

Objective: We sought to identify changes in neurological outcome over time following initial training and subsequent implementation of team-focused CPR in an inpatient setting where responders practice specific roles with emphasis on minimally interrupted chest compressions and early defibrillation. Methods: This retrospective pre- vs post-intervention study was conducted at an urban 900-bed teaching hospital and Level I Cardiac Resuscitation Center. We included adult patients suffering in-hospital cardiac arrest occurring in non-emergency department and non-intensive care unit areas who received CPR and/or defibrillation. We compared survival with good neurological outcome at time of hospital discharge in the one-year periods before and after implementation of team-focused CPR. To investigate skill degradation, we compared cumulative survival with good neurological outcome in 3-month intervals against the before team-focused CPR baseline. Trained research associates abstracted explicitly defined variables from electronic health records using a standardized form and data dictionary to achieve consistency between collaborators. Results: Of 296 IHCAs, 207 patients met inclusion criteria and were analyzed. In 104 patients before team-focused CPR initiation, survival with good neurological outcome was 21%. In the 12-month period following team-focused CPR initiation, survival with good neurological outcome was 31% in 101 patients, risk difference 9.9% (95% CI -2 to 22%; p = 0.14). By quarterly time intervals, following team-focused CPR implementation, the cumulative survival with good neurological outcome at 3 months was 42%; at 6 months 37%; at 9 months 31%; and at 12 months 31%. Conclusion: In our single-institution implementation of team-focused CPR for in-hospital cardiac arrest, outcomes significantly improved at 6 months before declining towards baseline.

Regionalization of post-cardiac arrest care: implementation of a cardiac resuscitation center.

BACKGROUND: Guidelines recommend standardized treatment of post-cardiac arrest patients to improve outcomes. However, the infrastructure, resources, and personnel required to meet the complex needs of cardiac arrest victims remain a barrier to care. Given that regionalization of time-dependent high-acuity illness is an emerging paradigm, the aim of the present study was to develop and implement a regionalized approach to post-cardiac arrest care. METHODS: We performed a prospective observational study on all patients treated in a regionalized clinical pathway from November 2007 through June 2011. All patients were enrolled after admission to an urban academic medical center. Clinical data including arrest and treatment variables, complications, and outcome were collected on consecutive patients with the use of a preformatted standard data collection tool using Utstein criteria. RESULTS: A total of 220 patients were enrolled; 127 (58%) patients were local direct admissions from our community, and 93 (42%) were transferred from 1 of 24 outlying referral hospitals. One hundred six (48%, 95% CI 38%-53%) patients survived to hospital discharge. The primary outcome of hospital survival with good neurologic function was observed in 94 (43%, 95% CI 32%-48%). There was no difference in survival with good neurologic outcome among local and referred patients. Overall 1-year survival was 44% (95% CI 38%-51%). Among patients discharged from the hospital with good neurologic function, 93% (95% CI 85%-97%) remained alive at 1 year. CONCLUSION: Development of a regionalized approach to post-cardiac arrest care using previously established referral relationships is feasible, and implementation of such an approach was clinically effective in our region.

Race Differences in Interventions and Survival After Out-of-Hospital Cardiac Arrest in North Carolina, 2010 to 2014.

Background Following the implementation of the HeartRescue project, with interventions in the community, emergency medical services, and hospitals to improve care and outcomes for out-of-hospital cardiac arrests (OHCA) in North Carolina, improved bystander and first responder treatments as well as survival were observed. This study aimed to determine whether these improvements were consistent across Black versus White individuals. Methods and Results Using the Cardiac Arrest Registry to Enhance Survival (CARES), we identified OHCA from 16 counties in North Carolina (population 3 million) from 2010 to 2014. Temporal changes in interventions and outcomes were assessed using multilevel multivariable logistic regression, adjusted for patient and socioeconomic neighborhood-level factors. Of 7091 patients with OHCA, 36.5% were Black and 63.5% were White. Black patients were younger, more females, had more unwitnessed arrests and non-shockable rhythm (Black: 81.0%; White: 75.4%). From 2010 to 2014, the adjusted probabilities of bystander cardiopulmonary resuscitation (CPR) went from 38.5% to 51.2% in White, P<0.001; and 36.9% to 45.6% in Black, P=0.002, and first-responder defibrillation went from 13.2% to 17.2% in White, P=0.002; and 14.7% to 17.3% in Black, P=0.16. From 2010 to 2014, survival to discharge only increased in White (8.0% to 11.4%, P=0.004; Black 8.9% to 9.5%, P=0.60), though, in shockable patients the probability of survival to discharge went from 24.8% to 34.6% in White, P=0.02; and 21.7% to 29.0% in Black, P=0. 10. Conclusions After the HeartRescue program, bystander CPR and first-responder defibrillation increased in both patient groups; however, survival only increased significantly for White patients.

Care and outcomes of urban and non-urban out-of-hospital cardiac arrest patients during the HeartRescue Project in Washington state and North Carolina.

AIM: We examined overall and temporal differences in out-of-hospital cardiac arrest (OHCA) care and outcomes by urban versus non-urban setting separately for North Carolina (NC) and Washington State (WA) during HeartRescue initiatives and associations of urban/non-urban settings with outcome by state. METHODS: OHCAs of presumed cardiac etiology from counties with complete registry enrollment in NC during 2010-2014 (catchment population = 3,143,809) and WA during 2011-2014 (catchment population = 3,653,506) were identified. Geospatial arrest location data and US Census classification were used to categorize urban areas with ≥50,000 versus non-urban <50,000 people. RESULTS: Included were 7731 NC cases (78.9% urban) and 4472 WA cases (85.8% urban). Bystander cardiopulmonary resuscitation (CPR) increased from 36.9% (2010) to 50.3% (2014) in NC non-urban areas versus 58.2% (2011) to 69.2% (2014) in WA; and from 39.3% to 51.1% in NC urban areas versus 52.4% to 61.8% in WA. Crude discharge survival odds ratio (OR) was 2.49 (95%CI 1.96-3.16) for urban versus non-urban NC cases not declared dead in field (N = 4241). Adjusted for age, sex, public location, bystander-witness status, time between emergency call and emergency medical service (EMS) arrival, calendar-year, bystander and first-responder CPR and defibrillation and direct PCI-center transport, OR was 1.30 (95%CI 0.98-1.73). In WA, corresponding crude and adjusted ORs were 1.38 (95%CI 0.99-1.93) and 1.46 (95%CI 1.00-2.13). In both states, bystander and first-responder CPR and defibrillation and direct PCI-hospital transport were associated with increased survival. CONCLUSIONS: During HeartRescue initiatives, bystander CPR increased in urban and non-urban locations. Bystander and first-responder interventions and direct PCI-hospital transport were associated with improved outcomes, including in non-urban areas.

Association of Bystander and First-Responder Efforts and Outcomes According to Sex: Results From the North Carolina HeartRescue Statewide Quality Improvement Initiative.

Background The Institute of Medicine has called for actions to understand and target sex-related differences in care and outcomes for out-of-hospital cardiac arrest patients. We assessed changes in bystander and first-responder interventions and outcomes for males versus females after statewide efforts to improve cardiac arrest care. Methods and Results We identified out-of-hospital cardiac arrests from North Carolina (2010-2014) through the CARES (Cardiac Arrest Registry to Enhance Survival) registry. Outcomes for men versus women were examined through multivariable logistic regression analyses adjusted for (1) nonmodifiable factors (age, witnessed status, and initial heart rhythm) and (2) nonmodifiable plus modifiable factors (bystander cardiopulmonary resuscitation and defibrillation before emergency medical services), including interactions between sex and time (ie, year and year2). Of 8100 patients, 38.1% were women. From 2010 to 2014, there was an increase in bystander cardiopulmonary resuscitation (men, 40.5%-50.6%; women, 35.3%-51.8%; P for each <0.0001) and in the combination of bystander cardiopulmonary resuscitation and first-responder defibrillation (men, 15.8%-23.0%, P=0.007; women, 8.5%-23.7%, P=0.004). From 2010 to 2014, the unadjusted predicted probability of favorable neurologic outcome was higher and increased more for men (men, from 6.5% [95% confidence interval (CI), 5.1-8.0] to 9.7% [95% CI, 8.1-11.3]; women, from 6.3% [95% CI, 4.4-8.3] to 7.4% [95% CI, 5.5-9.3%]); while adjusted for nonmodifiable factors, it was slightly higher but with a nonsignificant increase for women (from 9.2% [95% CI, 6.8-11.8] to 10.2% [95% CI, 8.0-12.5]; men, from 5.8% [95% CI, 4.6-7.0] to 8.4% [95% CI, 7.1-9.7]). Adding bystander cardiopulmonary resuscitation and defibrillation before EMS (modifiable factors) did not substantially change the results. Conclusions Bystander and first-responder interventions increased for men and women, but outcomes improved significantly only for men. Additional strategies may be necessary to improve survival among female cardiac arrest patients.

Out-of-hospital and emergency department utilization by adult homeless patients.

STUDY OBJECTIVE: Homeless adults visit emergency departments (EDs) nearly 4 times more often than the general population and are among the highest repeat visitors. Little research, however, has determined resource utilization patterns of homeless patients and the extent to which they may benefit from emergency care. The objectives of this study are to describe emergency medical services and hospital utilization by homeless patients and to estimate their benefit of ED care. METHODS: This was a retrospective cohort study performed at an urban safety-net hospital. All patients who presented to the ED during 2003 were identified. Simple random samples of 300 homeless adult patients and 300 nonhomeless adult patients were identified and included as the study sample. Variables collected included patient demographics, medical history, ED visit date and times, results of laboratory studies, disposition from the ED, diagnoses, ambulance use, number of previous ED visits, and estimated benefit of emergency treatment as determined by a previously developed consensus-based instrument. RESULTS: Homeless patients were slightly older (41 years [interquartile range (IQR) 34 to 48 years] versus 36 years [IQR 25 to 46 years]) and had substantially higher substance abuse histories but had similar medical and psychiatric comorbidities compared with nonhomeless patients. Homeless patients also spent more time in the ED per visit (4.4 hours [IQR 2.6 to 7.5 hours] versus 3.8 hours (IQR 2.1 to 5.7 hours]), were less likely to be admitted to the hospital (8% versus 19%), and were more likely to use ambulance services (51% versus 29%). Finally, homeless patients received a similar level of estimated benefit of emergency treatment compared with nonhomeless patients, and a substantial proportion of their visits was directly related to excessive alcohol use. CONCLUSION: Homeless adults commonly use emergency care resources, and medical benefit, although comparable to that of nonhomeless adults, is in many cases uncertain.

Factors Associated with Delayed Cooling in Cardiac Arrest Patients.

Therapeutic hypothermia has been shown to improve neurologic outcome in medical cardiac arrest patients, yet little is known about factors that delay target temperature achievement. Our primary aim was to identify factors associated with not achieving our institutional "door-to-cool" (DTC) performance goal (emergency department [ED] arrival to temperature of 34°C) of ≤4 hours. Secondary aims included whether achievement of DTC goal was associated with timing of bolus neuromuscular blockade (NMB), survival, or functional outcome. This was a retrospective cohort study of a medical cardiac arrest quality improvement (QI) database that included patients treated from November 2007 to August 2012. The database was queried for patient demographics, arrest characteristics, specific cooling techniques used, whether patients underwent emergent computed tomography imaging or cardiac catheterization, and patient outcomes. Logistic regression was used to assess the factors associated with DTC goal performance and outcomes. We enrolled 327 patients, median age 58, median return of spontaneous circulation (ROSC) time of 21 minutes (interquartile range [IQR] 14-29 minutes), and shockable initial rhythm in 61%. One hundred forty-four (44%) patients survived to hospital discharge, 133 (41%) with good functional outcome, as defined as cerebral performance category 1-2. Induction with cold IV fluids [OR 0.50 (CI: 0.29-0.85)] and NMB administration within 2 hours of ED arrival [OR 2.95 (CI: 1.17-7.43)] was associated with achieving DTC goal. Logistic regression showed that achievement of DTC goal ≤4 hours [OR 0.59 (0.32-1.09)] was not associated with good functional outcome. In our single-center cohort, initiation of cold intravenous fluids (IVF) and early NMB administration were associated with improved DTC goal performance of 4 hours. However, patients achieving DTC goals were not associated with improved outcomes.

Association of Public Health Initiatives With Outcomes for Out-of-Hospital Cardiac Arrest at Home and in Public Locations.

Importance: Little is known about the influence of comprehensive public health initiatives according to out-of-hospital cardiac arrest (OHCA) location, particularly at home, where resuscitation efforts and outcomes have historically been poor. Objective: To describe temporal trends in bystander cardiopulmonary resuscitation (CPR) and first-responder defibrillation for OHCAs stratified by home vs public location and their association with survival and neurological outcomes. Design, Setting, and Participants: This observational study reviewed 8269 patients with OHCAs (5602 [67.7%] at home and 2667 [32.3%] in public) for whom resuscitation was attempted using data from the Cardiac Arrest Registry to Enhance Survival (CARES) from January 1, 2010, through December 31, 2014. The setting was 16 counties in North Carolina. Exposures: Patients were stratified by home vs public OHCA. Public health initiatives to improve bystander and first-responder interventions included training members of the general population in CPR and in the use of automated external defibrillators, teaching first responders about team-based CPR (eg, automated external defibrillator use and high-performance CPR), and instructing dispatch centers on recognition of cardiac arrest. Main Outcomes and Measures: Association of resuscitation efforts with survival and neurological outcomes from 2010 through 2014. Results: Among home OHCA patients (n = 5602), the median age was 64 years, and 62.2% were male; among public OHCA patients (n = 2667), the median age was 68 years, and 61.5% were male. After comprehensive public health initiatives, the proportion of patients receiving bystander CPR increased at home (from 28.3% [275 of 973] to 41.3% [498 of 1206], P < .001) and in public (from 61.0% [275 of 451] to 70.5% [424 of 601], P = .01), while first-responder defibrillation increased at home (from 42.2% [132 of 313] to 50.8% [212 of 417], P = .02) but not significantly in public (from 33.1% [58 of 175] to 37.8% [93 of 246], P = .17). Survival to discharge improved for arrests at home (from 5.7% [60 of 1057] to 8.1% [100 of 1238], P = .047) and in public (from 10.8% [50 of 464] to 16.2% [98 of 604], P = .04). Compared with emergency medical services-initiated CPR and resuscitation, patients with home OHCA were significantly more likely to survive to hospital discharge if they received bystander-initiated CPR and first-responder defibrillation (odds ratio, 1.55; 95% CI, 1.01-2.38). Patients with arrests in public were most likely to survive if they received both bystander-initiated CPR and defibrillation (odds ratio, 4.33; 95% CI, 2.11-8.87). Conclusions and Relevance: After coordinated and comprehensive public health initiatives, more patients received bystander CPR and first-responder defibrillation at home and in public, which was associated with improved survival.

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

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 out-of-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.

Outcomes in Cardiac Arrest Patients due to Toxic Exposure Treated with Therapeutic Hypothermia.

The incidence and outcome of patients who undergo therapeutic hypothermia (TH) after toxin-induced cardiac arrest (TICA) is not previously described. Our study aimed to describe the incidence, epidemiologic characteristics, and outcomes of patients who experience TICA in a dedicated clinical pathway for post-cardiac arrest care between November 2007 and February 2013. All patients were treated in an evidence-based clinical pathway that included TH. Database and medical records were independently reviewed by investigators to ascertain TICA. TICA was defined as cardiac arrest (CA) directly and immediately caused by a xenobiotic exposure. All patients were enrolled at Carolinas Medical Center, an urban 874-bed teaching hospital that serves as a regional cardiac resuscitation center. All patients were adult victims of cardiac arrest who had obtained return of spontaneous circulation and were enrolled in a clinical pathway for post-cardiac arrest care that included TH. Three hundred eighty-nine patients underwent treatment following CA during the study period and 48 (12 %) were deemed TICA. Patients who suffered TICA were slightly younger, less likely to have an initial shockable rhythm, and less likely to receive bystander CPR as compared to non-toxic cases. TICA accounted for a significant proportion of patients in this study. Additional, larger studies are needed to fully elucidate the optimal role for TH in TICA.

Comparison of team-focused CPR vs standard CPR in resuscitation from out-of-hospital cardiac arrest: Results from a statewide quality improvement initiative.

BACKGROUND: Team-focused CPR (TFCPR) is a choreographed approach to cardiopulmonary resuscitation (CPR) with emphasis on minimally interrupted high-quality chest compressions, early defibrillation, discourages endotracheal intubation and encourages use of the bag-valve-mask (BVM) and/or blind-insertion airway device (BIAD) with a ventilation rate of 8-10 breaths/min to minimize hyperventilation. Widespread incorporation of TFCPR in North Carolina (NC) EMS agencies began in 2011, yet its impact on outcomes is unknown. OBJECTIVES: To determine whether TFCPR improves survival with good neurological outcome in out-of-hospital cardiac arrest (OHCA) patients compared to standard CPR. METHODS: This retrospective cohort analysis of NC EMS agencies reporting data to the Cardiac Arrest Registry for Enhanced Survival (CARES) database from January 2010 to June 2014 included adult, non-traumatic OHCA with presumed cardiac etiology where EMS performed CPR or patient received defibrillation. Exclusions were arrest terminated per EMS policy or DNR. EMS agencies self-reported the TFCPR implementation dates. Patients were categorized as receiving either TFCPR or standard CPR. The primary outcome was good neurologic outcome at time of hospital discharge defined as Pittsburgh Cerebral Performance Category (CPC) 1-2. RESULTS: Of 14,994 OHCAs, 14,129 patients were included for analysis with a mean age 65 (IQR 50-81) years, 61% male, 7.3% with good neurologic outcome, 24.3% with shockable initial rhythm, and 71.5% receiving TFCPR. Of the 3427 (24.3%) with an initial shockable rhythm, 739 (71.9%) had a good neurological outcome. Good neurologic outcome was higher with TFCPR [836 (8.3%, 95%CI 7.7-8.8%)] vs. standard CPR [193 (4.8%, 95%CI 4.2-5.5%)]. Logistic regression controlling for demographic and arrest characteristics revealed TFCPR (OR 1.5), witnessed arrest (OR 4.3), initial shockable rhythm (OR 7.1), and in-hospital hypothermia (OR 3.3) were associated with good neurologic outcome. Mechanical CPR device (OR 0.68), CPR feedback device (OR 0.47), and endotracheal intubation (OR 0.44) were associated with less likelihood for a good neurologic outcome. CONCLUSION: In our statewide OHCA cohort, TFCPR was associated with improved survival with good neurological outcome.

Survey of Individual and Institutional Risk Associated with the Use of Social Media.

INTRODUCTION: Residents and faculty in emergency medicine (EM) residency programs might be unaware of the professional and legal risks associated with the use of social media (SM). The objective of this study was to identify and characterize the types and reported incidence of unprofessional SM behavior by EM residents, faculty, and nurses and the concomitant personal and institutional risks. METHODS: This multi-site study used an 18-question survey tool that was distributed electronically to the leaders of multiple EM residency programs, members of the Council of Emergency Medicine Residency Directors (CORD), and the residents of 14 EM programs during the study period May to June 2013. RESULTS: We received 1,314 responses: 772 from residents and 542 from faculty. Both groups reported encountering high-risk-to-professionalism events (HRTPE) related to SM use by residents and non-resident providers (NRPs), i.e., faculty members and nurses. Residents reported posting of one of the following by a resident peer or nursing colleague: identifiable patient information (26%); or a radiograph, clinical picture or other image (52%). Residents reported posting of images of intoxicated colleagues (84%), inappropriate photographs (66%), and inappropriate posts (73%). Program directors (PDs) reported posting one of the following by NRPs and residents respectively: identifiable patient information (46% and 45%); a radiograph, clinical picture or other image (63% and 58%). PDs reported that NRPs and residents posted images of intoxicated colleagues (64% and 57%), inappropriate photographs (63% and 57%), or inappropriate posts (76% and 67%). The directors also reported that they were aware of or issued reprimands or terminations at least once a year (30% NRPs and 22% residents). Residents were more likely to post photos of their resident peers or nursing colleagues in an intoxicated state than were NRPs (p=0.0004). NRPs were more likely to post inappropriate content (p=0.04) and identifiable patient information (p=0.0004) than were residents. CONCLUSION: EM residents and faculty members cause and encounter HRTPE frequently while using SM; these events present significant risks to the individuals responsible and their associated institution. Awareness of these risks should prompt responsible SM use and consideration of CORD's Social Media Task Force recommendations.

Effect of prehospital initiation of therapeutic hypothermia in adults with cardiac arrest on time-to-target temperature.

OBJECTIVE: Despite growing adoption, the impact of prehospital initiation of therapeutic hypothermia on outcomes of cardiac arrest patients is unknown. The objective of this study was to determine if prehospital administration of cold intravenous fluids improved the time-to-target temperature. METHODS: All patients enrolled in an institutional post- cardiac arrest treatment pathway were prospectively registered into a quality assurance database. Patients undergoing cooling induction on hospital arrival were compared to those receiving a new treatment protocol initiated during the study period involving prehospital cooling with 4°C (39.2°F) normal saline. The primary outcome was the time-to-target temperature. Secondary outcomes included emergency medicine system transport time metrics, mortality, and neurologic status at discharge and 1 year. RESULTS: One hundred thirty-two patients were enrolled during the study period. The initial rhythm was ventricular fibrillation/tachycardia in 63% and asystole/pulseless electrical activity in 36%. Eighty patients received prehospital cooling and 52 patients did not and comprised the historical control group. Time-to-target temperatures were not significantly different between prehospital and hospital cooled groups (256 v. 271 minutes, respectively, p=0.64), nor was there any improvement in hospital survival (54% v. 50%, p=0.67), good neurologic outcome (49% v. 44%, p=0.61), or 1- year survival (49% v. 42%, p=0.46) between the two groups. Transport times were longer in the prehospital cooled group. CONCLUSIONS: Out-of-hospital cardiac arrest patients treated with prehospital cooling before arrival at our urban hospital did not have faster time-to-target temperature or improvement in outcomes compared to patients cooled immediately on emergency department arrival. Further research is needed to determine if any benefits exist from prehospital cooling prior to its widespread adoption.