Clinical paperEmergency department factors associated with survival after sudden cardiac arrest☆
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
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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.