Implementing the 2005 American Heart Association guidelines, including use of the impedance threshold device, improves hospital discharge rate after in-hospital cardiac arrest.

OBJECTIVE: To determine the impact of the 2005 American Heart Association cardiopulmonary resuscitation (CPR) guidelines, including use of an impedance threshold device (ITD), on survival after in-hospital cardiac arrest. METHODS: Two community hospitals that tracked outcomes after in-hospital cardiac arrest pooled and compared their hospital discharge rate before and after implementing the 2005 American Heart Association CPR guidelines (including ITD) in standardized protocols. In CPR we used the proper ventilation rate, allowed full chest-wall recoil, conducted continuous CPR following intubation, and used an ITD. We compared historical control data from a 12-month period at St Cloud Hospital, St Cloud, Minnesota, to data from a subsequent 18-month intervention phase. We compared historical control data from a 12-month period at St Dominic Hospital, Jackson, Mississippi to a subsequent 12-month intervention phase. 507 patients received CPR during the study period. Patient age and sex were similar in the control and intervention groups. RESULTS: The combined hospital discharge rate for patients with an in-hospital cardiac arrest was 17.5% in the control group (n=246 patients), which is similar to the national average, versus 28% in the intervention group (n=261 patients) (P=.006, odds ratio 1.83, 95% CI 1.17-2.88). The greatest benefit of the intervention was in patients with an initial rhythm of pulseless electrical activity: 14.4% versus 29.7% (P=.014, odds ratio 2.50, 95% CI 1.15, 5.58). Neurological function (as measured with the Cerebral Performance Category scale) in survivors at hospital discharge was similar between the groups. CONCLUSIONS: Implementation of improved ways to increase circulation during CPR increased the in-hospital discharge rate by 60%, compared to historical controls in 2 community hospitals. These data demonstrate that immediate care with improved means to circulate blood during CPR significantly reduces hospital mortality from inhospital sudden cardiac arrest.

A regional system for delivery of primary percutaneous coronary intervention in ST-elevation myocardial infarction: STEMI-St. Cloud.

BACKGROUND: Strategies of emergency care in the treatment of ST-segment elevation myocardial infarction (STEMI) have evolved rapidly over the past two decades to include primary percutaneous coronary intervention (PPCI) when possible. Most U.S.-based transfer programs still use complicated protocols that include fibrinolytic therapy often resulting in transfer delays, inappropriately applied therapy (wrong diagnosis) and bleeding and stroke complications. These protocols are often emphasized in low-volume centers. We implemented a program absent fibrinolytic therapy and applied it to a network of 25 participating hospitals over a 100-mile radius in central Minnesota. METHODS AND RESULTS: One-thousand consecutive patients ages 21 to 90 who presented within 12 hours of the onset of symptoms consistent with MI from April, 2004 to January, 2008 were included in this registry. Prior to transfer to the cardiac catheterization laboratory, patients received aspirin and heparin. Clopidogrel was added to the protocol in January, 2007. Glycoprotein (GP) IIb/IIIa inhibitors were typically utilized after diagnostic catheterization and prior to PPCI. Median door-to-balloon time was 56 minutes at the PCI Center and 110 minutes from referral sites (RS). Of the transfer patients, 71% underwent helicopter transfer. The success rate for PPCI was 99.4%. Despite inherent transfer delays, there was no difference in mortality between the PCI Center and RS. Overall mortality rates in-hospital, at 30 days, at 6 months, and 1 year were 2.1%, 2.9%, 3.8% and 4.5%, respectively, with follow up on 998 of 1,000 patients. In-hospital stroke, reinfarction and major bleeding were 0.7%, 2.0% and 2.7%, respectively. CONCLUSIONS: Despite increasing trends toward a pharmacoinvasive approach in transfer patients with STEMI, a protocol which stresses rapid transfer and PPCI results in excellent outcomes, with very low complication rates without fibrinolytic therapy.