Regionalization of Post-Cardiac Arrest Care
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1 Regionalization of Post-Cardiac Arrest Care David A. Pearson, MD, FACEP, FAAEM Department of Emergency Medicine
2 Disclosures I have no financial interest, arrangement, or affiliations and no commercial interests, ties, or grants related to material covered in this lecture. 1
3 Objectives - Regionalization Background Evidence: Code Cool Best Practices 2
4 Variation in Survival VF arrest Resuscitations Outcomes Consortium Survival to discharge Vancouver 25.0 Toronto 15.7 Seattle Portland 22.5 Pittsburgh 21.5 Ottawa 14.8 Milwaukee 26.0 Iowa 22.7 Dallas 9.5 Alabama Nichol JAMA. 2008;300(12):
5 U.S. Implementation 2005 Abella B, et al. Resuscitation Merchant RM, et al. Crit Care Med Laver SR, et al. Anaesthesia Bigham BL, et al. Resuscitation Toma A, et al. Crit Care Med
6 Regionalization Rationale IOM & AHA endorse regionalized systems Increase utilization of proven interventions Specialized resources at certain centers Correlation between case volume and patient outcome Mooney, et al. Circulation
7 Adult Chain of Survival 1. Immediate recognition & activation of EMS 2. Early CPR - emphasis on chest compressions 3. Rapid defibrillation 4. Effective advanced life support 5. Integrated post cardiac arrest care 6
8 AHA 2010: Post-Arrest Guidelines Optimize perfusion Identify & treat precipitating cause Transport to comprehensive post-cardiac arrest treatment system Acute coronary interventions Goal-directed critical care Hypothermia Peberdy, et al. Circulation
9 AHA 2010: Fifth Link to Survival Transport to comprehensive post-cardiac arrest treatment center 8
10 Japanese Experience Second link (early defibrillation) most important Fifth link (multidisciplinary post-resuscitation care in a regional center) next most important 9
11 Minneapolis Experience 150 mile catchment area 140 out-of-hospital cardiac arrest patients ROSC < 60 minutes Included: any initial rhythm, HD instability, STEMI Excluded: DNR, active bleeding, comatose before arrest Mooney, et al. Circulation
12 Minneapolis Experience: Arrest Characteristics Witnessed: 82% Bystander CPR: 66% VT/VF 76% STEMI 49% Shock 44% Downtime 22 minutes PEA/asystole 24% Mooney, et al. Circulation
13 Minneapolis Experience: Outcomes 56% survived 51% good neurological outcome 20% increased risk of death with every hour delay in initiation of cooling Time to goal temperature not significantly associated with survival Mooney, et al. Circulation
14 Minneapolis Heart Institute s Cool It Good Neurologic Outcomes Patient Group Good Neurologic Outcomes Local (n=17/33) 42% Referred/Transfer (n=58/107) 54% Age > 75 (n=9/30) 30% Asystole/PEA (n=7/32) 22% Downtime > 30 min (n=16/45) 36% 13
15 CMC Experience Local: 46% good neurological outcome Referred: 39% good neurological outcome Heffner, et al. AHJ
16 Code Cool: More Than Cooling Post-arrest resuscitation bundle Fluid resuscitation via cold IVF MAP > 70 mmhg Therapeutic hypothermia Avoid hyperoxia Avoid hyperventilation 15
17 Code Cool Implementation Timeline Nov-07 Code Cool Pathway Activation Sep-08 - Jun-10 Regional Outreach Campaign Oct-06 Jan-07 Apr-07 Jul-07 Oct-07 Jan-08 Apr-08 Jul-08 Oct-08 Jan-09 Apr-09 Jul-09 Oct-09 Jan-10 Apr-10 Jul-10 Nov-06 - Jul-07 Preparation and Planning 16
18 17
19 Code Cool Started November 2007 Total patients: 437 patients (Code Cool Protocol initiated) Total patients: 360 patients (Included in analysis) Transfers: 43% In-hospital arrests: 3% STEMIs: 9% 18
20 Code Cool Demographics Total patients (Completed protocol, included in analysis) Transfers In-patient arrests STEMI
21 Code Cool Outcomes: % Survival 20
22 Survival and Initial Rhythm Initial Rhythm Survived 2010 n=52 Survived with good neuro outcome Survived 2011 n=84 Survived with good neuro outcome Survived 2012 n=106 Survived with good neuro outcome VT/VF 57.6% 54.5% 59.6% 57.9% 56.1% 55.4% PEA 42.9% 35.7% 33.3% 33.3% 22.2% 12.5% Asystole 20% 0% 33.3% 26.7% 16.7% 16.7% 21
23 Code Cool Process: CMC Door to Target Temp Median Time 22
24 Code Cool Process Measures 23
25 Code Cool Outcome: % Pts with Persistent Hypotension during 0-6 hours 24
26 25
27 Regional Approach to Cardiovascular Emergencies Cardiac Arrest Resuscitation System Goal: To improve the survival from cardiac arrest by 50% 26
28 Hospital Response Resuscitation-Capable Hospital Resuscitate Initiate cooling Transfer Cardiac Arrest Center Hypothermia PCI ICD assessment & placement 27
29 Resuscitation-Capable Hospital ACLS protocols Baseline neurologic exam 2 large bore IV ECG = STEMI: activate STEMI plan Implement tx protocols for STEMI and cardiac arrest 28
30 Resuscitation-Capable Hospital Early notification of receiving hospital Early activation of transport plan Send medical records and EMTALA 29
31 Resuscitation-Capable Hospital Optimize BP to MAP > 80 mmhg Titrate EtCO2 for Consider CT imaging Induction of hypothermia (cold IVF) Sedation and paralysis Data measurement and feedback 30
32 Cardiac Arrest Center Ongoing neurological assessment & care Early coronary angiography if not a STEMI ICD evaluation 24/7 cath lab availability for STEMI Rehabilitation Plan 31
33 Hospital Response Resuscitation Capable Hospital Resuscitate Initiate cooling Transfer Cardiac Arrest Center Hypothermia PCI ICD assessment & placement 32
34 Take Home Aggressively resuscitate Establish transfer protocols Cardiac arrest centers 33
35 Questions? 34
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