Statewide regionalization of postarrest care for out-of-hospital cardiac arrest: association with survival and neurologic outcome.

STUDY OBJECTIVE: For out-of-hospital cardiac arrest, authoritative, evidence-based recommendations have been made for regionalization of postarrest care. However, system-wide implementation of these guidelines has not been evaluated. Our hypothesis is that statewide regionalization of postarrest interventions, combined with emergency medical services (EMS) triage bypass, is associated with improved survival and neurologic outcome. METHODS: This was a prospective before-after observational study comparing patients admitted to cardiac receiving centers before implementation of the interventions ("before") versus those admitted after ("after"). In December 2007, the Arizona Department of Health Services began officially recognizing cardiac receiving centers according to commitment to provide specified postarrest care. Subsequently, the State EMS Council approved protocols allowing preferential EMS transport to these centers. Participants were adults (≥ 18 years) experiencing out-of-hospital cardiac arrest of presumed cardiac cause who were transported to a cardiac receiving center. Interventions included (1) implementation of postarrest care at cardiac receiving centers focusing on provision of therapeutic hypothermia and coronary angiography or percutaneous coronary interventions (catheterization/PCI); and (2) implementation of EMS bypass triage protocols. Main outcomes included discharged alive from the hospital and cerebral performance category score at discharge. RESULTS: During the study (December 1, 2007, to December 31, 2010), 31 hospitals were recognized as cardiac receiving centers statewide. Four hundred forty patients were transported to cardiac receiving centers before and 1,737 after. Provision of therapeutic hypothermia among patients with return of spontaneous circulation increased from 0% (before: 0/145; 95% confidence interval [CI] 0% to 2.5%) to 44.0% (after: 300/682; 95% CI 40.2, 47.8). The post return of spontaneous circulation catheterization PCI rate increased from 11.7% (17/145; 95% CI 7.0, 18.1) before to 30.7% (210/684; 95% CI 27.3, 34.3) after. All-rhythm survival increased from 8.9% (39/440) to 14.4% (250/1,734; adjusted odds ratio [aOR] = 2.22; 95% CI 1.47 to 3.34). Survival with favorable neurologic outcome (cerebral performance category score = 1 or 2) increased from 5.9% (26/439) to 8.9% (153/1,727; aOR = 2.26 [95% CI 1.37, 3.73]). For witnessed shockable rhythms, survival increased from 21.4% (21/98) to 39.2% (115/293; aOR = 2.96 [95% CI 1.63, 5.38]) and cerebral performance category score = 1 or 2 increased from 19.4% (19/98) to 29.8% (87/292; aOR = 2.12 [95% CI 1.14, 3.93]). CONCLUSION: Implementation of a statewide system of cardiac receiving centers and EMS bypass was independently associated with increased overall survival and favorable neurologic outcome. In addition, these outcomes improved among patients with witnessed shockable rhythms.

Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest.

CONTEXT: Chest compression-only bystander cardiopulmonary resuscitation (CPR) may be as effective as conventional CPR with rescue breathing for out-of-hospital cardiac arrest. OBJECTIVE: To investigate the survival of patients with out-of-hospital cardiac arrest using compression-only CPR (COCPR) compared with conventional CPR. DESIGN, SETTING, AND PATIENTS: A 5-year prospective observational cohort study of survival in patients at least 18 years old with out-of-hospital cardiac arrest between January 1, 2005, and December 31, 2009, in Arizona. The relationship between layperson bystander CPR and survival to hospital discharge was evaluated using multivariable logistic regression. MAIN OUTCOME MEASURE: Survival to hospital discharge. RESULTS: Among 5272 adults with out-of-hospital cardiac arrest of cardiac etiology not observed by responding emergency medical personnel, 779 were excluded because bystander CPR was provided by a health care professional or the arrest occurred in a medical facility. A total of 4415 met all inclusion criteria for analysis, including 2900 who received no bystander CPR, 666 who received conventional CPR, and 849 who received COCPR. Rates of survival to hospital discharge were 5.2% (95% confidence interval [CI], 4.4%-6.0%) for the no bystander CPR group, 7.8% (95% CI, 5.8%-9.8%) for conventional CPR, and 13.3% (95% CI, 11.0%-15.6%) for COCPR. The adjusted odds ratio (AOR) for survival for conventional CPR vs no CPR was 0.99 (95% CI, 0.69-1.43), for COCPR vs no CPR, 1.59 (95% CI, 1.18-2.13), and for COCPR vs conventional CPR, 1.60 (95% CI, 1.08-2.35). From 2005 to 2009, lay rescuer CPR increased from 28.2% (95% CI, 24.6%-31.8%) to 39.9% (95% CI, 36.8%-42.9%; P < .001); the proportion of CPR that was COCPR increased from 19.6% (95% CI, 13.6%-25.7%) to 75.9% (95% CI, 71.7%-80.1%; P < .001). Overall survival increased from 3.7% (95% CI, 2.2%-5.2%) to 9.8% (95% CI, 8.0%-11.6%; P < .001). CONCLUSION: Among patients with out-of-hospital cardiac arrest, layperson compression-only CPR was associated with increased survival compared with conventional CPR and no bystander CPR in this setting with public endorsement of chest compression-only CPR.