Survival and neurologic outcome after out-of-hospital cardiac arrest: results one year after regionalization of post-cardiac arrest care in a large metropolitan area.

BACKGROUND: Post-resuscitation care of cardiac arrest patients at specialized centers may improve outcome after out-of-hospital cardiac arrest (OOHCA). This study describes experience with regionalized care of resuscitated patients. METHODS: Los Angeles (LA) County established regionalized cardiac care in 2006. Since 2010, protocols mandate transport of nontraumatic OOHCA patients with field return of spontaneous circulation (ROSC) to a STEMI Receiving Center (SRC) with a hypothermia protocol. All SRC report outcomes to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report the first year's data. The primary outcome was survival with good neurologic outcome, defined by a Cerebral Performance Category (CPC) score of 1 or 2. RESULTS: The SRC treated 927 patients from April 2011 through March 2012 with median age 67; 38% were female. There were 342 patients (37%) who survived to hospital discharge. CPC scores were unknown in 47 patients. Of the 880 patients with known CPC scores, 197 (22%) survived to hospital discharge with a CPC score of 1 or 2. The initial rhythm was VF/VT in 311 (34%) patients, of whom 275 (88%) were witnessed. For patients with an initial shockable rhythm, 183 (59%) survived to hospital discharge and 120 (41%) had survival with good neurologic outcome. Excluding patients who were alert or died in the ED, 165 (71%) patients with shockable rhythms received therapeutic hypothermia (TH), of whom 67 (42%) had survival with good neurologic outcome. Overall, 387 patients (42%) received TH. In the TH group, the adjusted OR for CPC 1 or 2 was 2.0 (95%CI 1.2-3.5, p = 0.01), compared with no TH. In contrast, the proportion of survival with good neurologic outcome in the City of LA in 2001 for all witnessed arrests (irrespective of field ROSC) with a shockable rhythm was 6%. CONCLUSION: We found higher rates of neurologically intact survival from OOHCA in our system after regionalization of post-resuscitation care as compared to historical data.

Reperfusion paradox in ST-segment elevation myocardial infarction.

A transformation in ST-segment elevation myocardial infarction (STEMI) care in the United States has unfolded. It asserts superior reperfusion with primary percutaneous coronary intervention (PPCI) over fibrinolysis on the basis of studies showing the former method to be superior for reperfusion of patients with STEMI. Although clear benefit has resulted from national programs directed toward achieving shorter times to PPCI in facilities with around-the-clock access, most patients present to non-PPCI hospitals. Because delay to PPCI for most patients with STEMI presenting to non-PPCI centers remains outside current guidelines, many are denied benefit from pharmacologic therapy. This article describes why this approach creates a treatment paradox in which more effort to improve treatment for patients with PPCI for acute STEMI often leads to unnecessary avoidance and delay in the use of fibrinolysis. Recent evidence confirms the unfavorable consequences of delay to PPCI and that early prehospital fibrinolysis combined with strategic mechanical co-interventions affords excellent outcomes. The authors believe it is time to embrace an integrated dual reperfusion strategy to best serve all patients with STEMI.

King's College London, a cardiac centre of excellence: will it only be possible to deliver the best cardiovascular medicine in 'capital cities' in the future?

New developments at King's College, London, suggest that the complexity of modern cardiovascular medicine, and the enormous prospects for future advances, means that smaller cities will find it hard to compete, reports Barry Shurlock, MA, PhD.

New knowledge, innovations, and improvement in a Magnet® Children's Hospital Cardiac Center.

Bedside nurses involved in research and evidence-based practice (EBP) have the ability to change policies, patient care, and outcomes. This article describes the journey of a research committee using the Magnet® component of new knowledge, innovation, and improvements. Using several tools, the unit-based committee developed skills in meeting management, nursing research methods, and EBP. Focusing to improve family and nurse communication about the plan of care, the committee recommended changes in the existing Plan of Care tool, including family input and recommendations for families to view and add to the sheet and participate in daily rounds, which was not the standard practice. Since this intervention was implemented, patient satisfaction has increased, as well as nurse engagement and intent to stay. This project exemplifies how nurse-driven innovations and family partnership led to new knowledge, innovations in learning about research, applying it to practice, and improving practice.

Status and future needs of regional adult congenital heart disease centers in Japan.

BACKGROUND: Although the prevalence of adult congenital heart disease (ACHD) in Japan continues to rise, the number and geographic distribution of facilities potentially serving as regional ACHD centers remains unknown. We examined trends in ACHD care in Japan to identify needs and to determine potential regional responses to this growing patient population. METHODS AND RESULTS: A descriptive, cross-sectional, nationwide survey was conducted to assess the status and needs of cardiology specialists related to providing ACHD care. Questionnaires were mailed to 138 cardiology departments located in 8 geographical regions throughout Japan; respondents were asked to document the status and future direction of ACHD care for each facility. Of the 109 facilities that responded, approximately one-third currently treat or plan to treat all ACHD patients. Fourteen facilities (12.8%) fulfilled all criteria for becoming regional ACHD centers. Although each regional center was projected to serve a population of 9.1 million, in 2 regions, no centers possessed the necessary care structure. CONCLUSIONS: Our findings revealed a shortage of adult cardiologists dedicated to ACHD care. Moreover, basic as well as formal fellowship ACHD training was deemed necessary. In Japan, the number of potential regional ACHD centers has just reached international standards. However, based on the geographic gaps documented here, a strategy other than regional centralization might be required to deliver adequate ACHD care to rural areas.

From hypertrophic cardiomyopathy centers to inherited cardiovascular disease centers in Europe. A small or a major step? A position paper from the Nucleus of the Working Group on Myocardial and Pericardial Diseases of the Portuguese Society of Cardiology.

The prevalence, complexity, clinical importance, heterogeneity and unpredictability of inherited cardiovascular diseases make the development of inherited cardiovascular disease centers an inevitability, with the ultimate goal of reducing the morbidity and mortality associated with these conditions. An inherited cardiovascular disease center may be seen as a subunit of a cardiology department, with health professionals specializing in these types of disorders, organized to provide excellence in all related areas, including diagnosis, treatment, followup, prevention, risk stratification and prognosis. Among its objectives are the development of action protocols and the creation of databases that enable patients to be included in national and international research networks. To achieve these objectives these centers should include functional units of clinical and basic sciences, research, training and education, acting in harmony in a holistic approach to patients and their families. As most experience on inherited cardiovascular diseases is based on hypertrophic cardiomyopathy and on "hypertrophic cardiomyopathy centers", these centers represent an excellent opportunity to learn how to set up inherited cardiovascular disease centers. European centers will differ from country to country, reflecting the heterogeneity of national health systems, but will share a common core, presented in this document. Though we are aware that this ambitious project is not at all easy and may be difficult to implement in its entirety--in fact we consider it a major step--our position is that all the efforts to achieve it are worthwhile, considering that the main goal will always be the well-being of those affected by these particular disorders.

The Joint Commission's disease-specific care certification for destination therapy ventricular assist devices.

The Centers for Medicare and Medicaid Services announced that all hospitals implanting ventricular assist devices are required to have certification from the The Joint Commission for disease-specific care destination therapy with a ventricular assist device effective March 27, 2009, in order to receive Medicare reimbursement for services rendered to patients who have devices implanted for destination therapy. On February 23, 2007, The Joint Commission released the certification requirements for ventricular assist devices implanted for destination therapy in an 8-page document so that hospitals could prepare to meet the 2009 certification deadline. The Artificial Heart Program of the University of Pittsburgh Medical Center undertook a multidisciplinary project, under the guidance of the nurse coordinator, to prepare the hospital and program for a precertification survey by The Joint Commission for disease-specific destination therapy ventricular assist device certification. The Presbyterian Hospital Artificial Heart Program was awarded The Joint Commission's device-specific certification for destination therapy with ventricular assist devices in June 2008.

[Quality and performance in cardiac pacing and electrophysiology. An update to the 2010 Italian Association of Arrhythmology and Cardiac Pacing (AIAC) - Italian Federation of Cardiology (IFC) Document 'Structure and functional organization of Arrhythmology']. / Qualità e performance in Elettrostimolazione ed Elettrofisiologia. Aggiornamento al documento dell'Associazione Italiana di Aritmologia e Cardiostimolazione (AIAC) ­ Federazione Italiana di Cardiologia (FIC) 2010 "Struttura e organizzazione funzionale dell'Aritmologia".

In the last decade the field of cardiac pacing and electrophysiology underwent major advancements thanks to both new ways of arrhythmia management and technological innovations. At the same time, the clinical competence and the procedural qualitative level of Cardiac Rhythm Centers have increased significantly. In 2010 an ad hoc Committee of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) and the Italian Federation of Cardiology (FIC) published a consensus document on the organization of Cardiac Rhythm Centers and on the standards of professional practice in pacing and electrophysiology in Italy. In particular, this document focused on the minimal requirements of a Center to be qualified as suitable to perform first, second and third-level cardiac pacing and electrophysiology activities. However, most of these indicators have been overcome over time. Thus, an update of the previously published organizational model appeared necessary. In this document several new requirements and indicators about the organization and performance of both operators and Cardiac Arrhythmia Centers have been introduced. These include: (i) "structural and procedural requirements" (types of diagnostic and therapeutic procedures performed, logistic structures, healthcare staff and technologies), (ii) "activity indicators" (number of procedures performed); (iii) "appropriateness indicators" (adherence to guideline recommendations); (iv) "outcome indicators" (procedural success and complications); and (v) "quality of care indicators" (management and continuity of care levels). By applying these requirements and indicators, each center can optimize its procedures, increasing its performance and effectiveness. Finally, a new model for the organization of the Italian network of Cardiac Arrhythmia Centers is also suggested.

When is your surgeon good enough? When do you need a "referent surgeon"?

Recent American College of Cardiology/American Heart Association guidelines recommend mitral valve repair in asymptomatic patients at an experienced center, assuming the likelihood for repair is > or = 90%. This has raised the question of how you define an experienced center (or surgeon). This article describes thoughts on the criteria that should make up a Center of Excellence: surgical training; intraoperative echocardiography; high volume; cardiology involvement; audit of clinical outcomes and outcomes of repair; and associated surgery for atrial fibrillation and tricuspid regurgitation. High-volume programs (> or = 140 mitral valve operations per year) have the lowest mortality and highest repair rate. Although some pathologic conditions may be repaired with a high degree of certainty by experienced (nonreferent) surgeons, considerable variation still exists. Recent publications of repair rates and outcomes using minimally invasive surgery and conventional surgery highlight this variability.

Decrease in acute coronary syndrome mortality in Pleven district: implementation of scientific evidence into everyday practice.

Cardiovascular mortality in Bulgaria has increased for the last 25 years, contrary to the rest of the EU countries. One of the reasons is high in-hospital mortality due to acute myocardial infarction. The Bulgarian Cardiac Institute has established a modern cardiac hospital with a catheterization laboratory (cathlab) in the Medical University in Pleven, which helps it decrease acute coronary syndrome (ACS) mortality, taking all the necessary steps according to the guidelines of the European Society of Cardiology (ESC).

Chest pain center accreditation is associated with better performance of centers for Medicare and Medicaid services core measures for acute myocardial infarction.

The aim of this study was determine whether hospitals accredited by the Society of Chest Pain Centers hospitals (accredited chest pain centers [ACPCs]) are associated with better performance regarding Centers for Medicare and Medicaid Services core measures for acute myocardial infarction (AMI) than nonaccredited hospitals. The study was a retrospective, observational cohort study of hospitals reporting Centers for Medicare and Medicaid Services core measures for AMI from January 1, 2005, to December 31, 2005, on the basis of the presence or absence of Society of Chest Pain Centers accreditation. Data were obtained from the Web sites of the Centers for Medicare and Medicaid Services (Hospital Compare), Society of Chest Pain Centers listings, and the American Hospital Directory. Groups were compared in terms of demographics and mean percentage compliance with all 8 AMI core measures. Student's t test, chi-square analysis, and logistic regression were used to analyze bivariate relations. Multivariate logistic regression models used a propensity-score adjustment factor. Of the 4,197 hospitals that reported core measures for AMI, 178 (4%) were accredited and 4,019 (96%) were not. ACPCs had been accredited for an average of 12 months and were larger (378 vs 204 beds), more often teaching hospitals (52% vs 30%), and more often urban (95% vs 69%) (all p <0.0001). There were 395,250 patients with AMIs, of whom 55,418 (14%) presented to ACPCs and 339,832 (86%) presented to nonaccredited hospitals. There was significantly greater compliance with all 8 AMI core measures at ACPCs (p <0.0001), except for lytic therapy <30 minutes after arrival (p = 0.04), for which unadjusted performance was the same. In conclusion, ACPCs were associated with better compliance with Centers for Medicare and Medicaid Services core measures and saw a greater proportion of patients with AMIs.

Toward standardization of care: The feeding readiness assessment after congenital cardiac surgery.

BACKGROUND: Feeding practices after neonatal and congenital heart surgery are complicated and variable, which may be associated with prolonged hospitalization length of stay (LOS). Systematic assessment of feeding skills after cardiac surgery may earlier identify those likely to have protracted feeding difficulties, which may promote standardization of care. METHODS: Neonates and infants ≤3 months old admitted for their first cardiac surgery were retrospectively identified during a 1-year period at a single center. A systematic feeding readiness assessment (FRA) was utilized to score infant feeding skills. FRA scores were assigned immediately prior to surgery and 1, 2, and 3 weeks after surgery. FRA scores were analyzed individually and in combination as predictors of gastrostomy tube (GT) placement prior to hospital discharge by logistic regression. RESULTS: Eighty-six patients met inclusion criteria and 69 patients had complete data to be included in the final model. The mean age of admit was five days and 51% were male. Forty-six percent had single ventricle physiology. Twenty-nine (42%) underwent GT placement. The model containing both immediate presurgical and 1-week postoperative FRA scores was of highest utility in predicting discharge with GT (intercept odds = 10.9, P = .0002; sensitivity 69%, specificity 93%, AUC 0.913). The false positive rate was 7.5%. CONCLUSIONS: In this analysis, systematic and standardized measurements of feeding readiness employed immediately before and one week after congenital cardiac surgery predicted need for GT placement prior to hospital discharge. The FRA score may be used to risk stratify patients based on likelihood of prolonged feeding difficulties, which may further improve standardization of care.

Performance of top-ranked heart care hospitals on evidence-based process measures.

BACKGROUND: Despite the increasing availability of evidence-based clinical performance measure data that compares the performances of US hospitals, the general public continues to rely on more popular resources such as the US News & World Report annual publication of "America's Best Hospitals" for information on hospital quality. This study evaluated how well hospitals ranked on the US News & World Report list of top heart and heart surgery hospitals performed on acute myocardial infarction and heart failure measures derived from American College of Cardiology and American Heart Association clinical treatment guidelines. METHODS AND RESULTS: This study identified 774 hospitals, including 41 of the US News & World Report top 50 heart and heart surgery hospitals. To compare hospitals, 10 rate-based performance measures (6 addressing processes of acute myocardial infarction care and 4 addressing heart failure care), were aggregated into a cardiovascular composite measure. As a group, the US News & World Report hospitals performed statistically better than their peers (mean, 86% versus 83%; P < 0.05). Individually, however, only 23 of the US News & World Report hospitals achieved statistically better-than-average performance compared with the population average, whereas 9 performed significantly worse (P < 0.05). One hundred sixty-seven hospitals in this study routinely implemented evidenced-based heart care > or = 90% of the time. CONCLUSIONS: A number of the US News & World Report top hospitals fell short in regularly applying evidenced-based care for their heart patients. At the same time, many lesser known hospitals routinely provided cardiovascular care that was consistent with nationally established guidelines.

Use of hierarchical models to evaluate performance of cardiac surgery centres in the Italian CABG outcome study.

BACKGROUND: Hierarchical modelling represents a statistical method used to analyze nested data, as those concerning patients afferent to different hospitals. Aim of this paper is to build a hierarchical regression model using data from the "Italian CABG outcome study" in order to evaluate the amount of differences in adjusted mortality rates attributable to differences between centres. METHODS: The study population consists of all adult patients undergoing an isolated CABG between 2002-2004 in the 64 participating cardiac surgery centres.A risk adjustment model was developed using a classical single-level regression. In the multilevel approach, the variable "clinical-centre" was employed as a group-level identifier. The intraclass correlation coefficient was used to estimate the proportion of variability in mortality between groups. Group-level residuals were adopted to evaluate the effect of clinical centre on mortality and to compare hospitals performance. Spearman correlation coefficient of ranks (rho) was used to compare results from classical and hierarchical model. RESULTS: The study population was made of 34,310 subjects (mortality rate = 2.61%; range 0.33-7.63). The multilevel model estimated that 10.1% of total variability in mortality was explained by differences between centres. The analysis of group-level residuals highlighted 3 centres (VS 8 in the classical methodology) with estimated mortality rates lower than the mean and 11 centres (VS 7) with rates significantly higher. Results from the two methodologies were comparable (rho = 0.99). CONCLUSION: Despite known individual risk-factors were accounted for in the single-level model, the high variability explained by the variable "clinical-centre" states its importance in predicting 30-day mortality after CABG.