Elsevier

Resuscitation

Volume 84, Issue 3, March 2013, Pages 292-297
Resuscitation

Clinical paper
Emergency department factors associated with survival after sudden cardiac arrest

https://doi.org/10.1016/j.resuscitation.2012.10.013Get rights and content

Abstract

Background

Sudden cardiac arrest (SCA) is a leading cause of death in the US. Recent innovations in post-arrest care have been demonstrated to increase survival. However, little is known about the impact of emergency department (ED) and hospital characteristics on survival to hospital admission and ultimate outcome.

Objective

We sought to describe the incidence of SCA presenting to the ED and to identify ED and hospital characteristics associated with survival to hospital admission.

Methods

We identified patients with diagnoses of atraumatic cardiac arrest or ventricular fibrillation (ICD-9 427.5 or 427.41) in the 2007 Nationwide Emergency Department Sample (NEDS), a nationally representative estimate of all ED admissions in the United States. We defined SCA as cardiac arrest in the out-of-hospital or ED settings. We used the NEDS sample design to generate nationally representative estimates of the incidence of SCA that presents to EDs. We performed unadjusted and adjusted analyses to examine the relation between patient, ED, and hospital characteristics and outcome using logistic regression. Our primary outcome was survival to hospital admission. Survival to hospital discharge was a secondary outcome. Data are presented as odds ratios (OR) with 95% confidence intervals (CI).

Results

Of the 966 hospitals in the NEDS, 933 (96.6%) reported at least one SCA and were included in the analysis. We identified 38,593 cases of cardiac arrest representing an estimated 174,982 cases nationally. Overall ED SCA survival to hospital admission was 26.2% and survival to discharge was 15.7%. Greater survival to admission was seen in teaching hospitals (OR 1.3 95% CI 1.1–1.5, p = 0.001), hospitals with ≥20,000 annual ED visits (OR 1.3 95% CI 1.1–1.6, p = 0.003), and hospitals with percutaneous coronary intervention capability (OR 1.6 95% CI 1.4–1.8, p < 0.001). Higher SCA volume (>40 annually) was associated with lower survival overall (OR 0.7 95% 0.6–0.9, p = 0.010), but not when transferred patients were excluded from the analysis (OR 0.8 95% CI 0.6–1.1, p = 0.116).

Conclusions

An estimated 175,000 cases of SCA present to or occur in US EDs each year. Percutaneous coronary intervention capability, ED volume, and teaching status were associated with higher survival to hospital admission. Emergency departments with higher annual SCA volume had lower survival rates, possibly because they transfer fewer patients. An improved understanding of the contribution of ED care to survival following SCA may be useful in advancing our understanding of how best to organize a system of care to ensure optimal outcomes for patients with SCA.

Introduction

Sudden cardiac arrest (SCA) is a leading cause of death in the United States. Estimates of the annual incidence of out-of-hospital SCA, range from 300,000 to 350,000 each year.1 Outcomes remain poor for out-of-hospital SCA patients, with a median survival to hospital discharge of approximately 7.8% and significant regional variability.2

Advances including early defibrillation, high quality cardiopulmonary resuscitation (CPR), and improvements in the Advanced Cardiac Life Support algorithm have led to increased rates of ROSC among patients with treated SCA.3, 4, 5 In addition, there has been growing recognition of a post-cardiac arrest syndrome, characterized by a specific constellation of pathologies. A number of interventions during this post-arrest period, including therapeutic hypothermia, hemodynamic optimization, and percutaneous coronary intervention (PCI) have been shown to improve survival.6, 7, 8, 9, 10, 11 Despite studies demonstrating their feasibility and benefit, most modalities of post-cardiac arrest care are infrequently implemented.12, 13

Largely due to variability in both SCA survival and implementation of post-arrest care, the AHA and other groups have proposed that centers with expertise in caring for SCA patients preferentially receive them in a regionalized system of post-cardiac arrest care.14, 15, 16 Although regionalized care has not been proven for cardiac arrest, early efforts are promising, and benefits have been seen for other acute medical conditions.4, 17 The concept of regionalization is rooted in the US trauma system, in which a significant survival benefit has been demonstrated for injured patients treated at specialized centers.18, 19, 20, 21 Similar systems have been proposed and implemented for other disease states such as acute coronary syndrome and stroke.22, 23, 24 Efforts to develop cardiac resuscitation centers (CRCs) and regionalize post-cardiac arrest care are already underway, and a credentialing system was recently developed by the AHA.14, 15, 16, 25 A comprehensive system of post-arrest care, which includes among many interventions a policy allowing EMS personnel to selectively transport cardiac arrest patients to CRCs, has been implemented in Arizona and associated with improved outcomes.4, 17 It remains unclear, however, which hospital factors are associated with improved outcomes for patients with sudden cardiac arrest.

A prior study by our group demonstrated significant variability in cardiac arrest survival among hospitals, with improved survival in centers that treat a higher volume of cardiac arrest patients in their intensive care units.26 Others have shown variable association between hospital-level factors and SCA survival.27, 28, 29 This study will examine ED and hospital factors associated with survival to admission in SCA. We hypothesized that large, urban, academic hospitals with higher SCA volumes will have better survival to hospital admission than smaller, rural, low SCA volume hospitals.

Section snippets

Selection of study subjects

Data were obtained from the Nationwide Emergency Department Sample (NEDS). The NEDS is the largest all-payer database in the United States and was developed, maintained, and made available through the Healthcare Cost & Utilization Project (HCUP) of the Agency for Healthcare Research and Quality. The NEDS is constructed annually using records from State Emergency Department Databases and State Inpatient Databases. In 2007, the year used for this study, information from 966 hospitals in 27 states

Characteristics of hospitals and study subjects

Hospital and patient characteristics are displayed in Table 1, Table 2. Of the 966 hospitals included in the NEDS, 933 (96.6%) documented at least one case of cardiac arrest in 2007, representing 4637 hospitals nationally. Of these hospitals, 74.2% admitted at least one cardiac arrest patient from the ED. In total, 38,593 cases of cardiac arrest were identified, representing an estimated 174,982 cases of SCA that present to or occur in EDs nationally.

A total of 8008 patients were excluded (1786

Discussion

In this study, we sought to describe the incidence of SCA presenting to EDs in the US and to identify ED factors associated with higher survival to hospital admission. We found that a number of factors including ED volume, teaching status, and PCI capability were associated with higher survival to hospital admission among patients with SCA.

We previously demonstrated significant variability for cardiac arrest patients who survived to be admitted to the hospital, and in this analysis we sought to

Conclusion

Nearly 175,000 cases of SCA present to or occur in EDs in the US each year. Percutaneous coronary intervention capability, ED volume, and teaching status were associated with higher survival to hospital admission. Emergency departments with higher annual SCA volume had lower survival rates, possibly because they transfer fewer patients. An improved understanding of the contribution of ED care to survival following SCA may be useful in advancing our understanding of how best to organize a system

Conflict of interest statement

Nicholas Johnson and Rama Salhi have no disclosures. Benjamin Abella receives research funding from the National Institutes of Health, Philips, MedTronic Foundation, and the Doris Duke Foundation. He receives speaking honoraria from Medivance and provides advisory for Heartsine Corporation. Robert Neumar has no disclosures. David Gaieski receives research support and consulting fees from Stryker. Brendan Carr receives research funding from Centers for Disease Control and Prevention, National

References (46)

  • M.W. Donnino et al.

    The development and implementation of cardiac arrest centers

    Resuscitation

    (2011)
  • V.L. Roger et al.

    Heart disease and stroke statistics—2011 update: a report from the American Heart Association

    Circulation

    (2011)
  • G. Nichol et al.

    Regional variation in out-of-hospital cardiac arrest incidence and outcome

    JAMA

    (2008)
  • B.J. Bobrow et al.

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

    JAMA

    (2010)
  • Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest

    N Engl J Med

    (2002)
  • S.A. Bernard et al.

    Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia

    N Engl J Med

    (2002)
  • M.A. Peberdy et al.

    Part 9: post-cardiac arrest care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

    Circulation

    (2010)
  • R.M. Merchant et al.

    Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest [see comment]

    Crit Care Med

    (2006)
  • R.A. Felberg et al.

    Hypothermia after cardiac arrest: feasibility and safety of an external cooling protocol

    Circulation

    (2001)
  • G. Nichol et al.

    Regional systems of care for out-of-hospital cardiac arrest: a policy statement from the American Heart Association

    Circulation

    (2010)
  • K.G. Lurie et al.

    Level 1 cardiac arrest centers: learning from the trauma surgeons

    Acad Emerg Med

    (2005)
  • A.R. Panchal et al.

    Impact of an AHA guideline-based. Statewide postarrest system of care on survival from out-of-hospital cardiac arrest

    Circulation

    (2010)
  • P.G. Trafton et al.

    Regionalization of trauma care

    N Engl J Med

    (1980)
  • Cited by (46)

    View all citing articles on Scopus

    A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.10.013.

    View full text