STEMI Center Treatment and Neurologic Recovery for Cardiac Arrest
STEMI Center Treatment and Neurologic Recovery for Cardiac Arrest
We found that treatment at an STEMI center after resuscitation from OHCA is associated with increased odds of good neurologic recovery. Our results are consistent with 2 smaller studies showing higher survival among resuscitated OHCA patients treated at hospitals with cardiac catheterization and with 2 larger studies showing higher survival among OHCA patients transported to at tertiary or critical care hospitals. These data suggest that patients resuscitated from OHCA would benefit from regionalized care at an STEMI center. Regionalized care improves processes of care in STEMI, trauma, stroke, and critical illness, and regionalized systems of care are well developed for patients with STEMI. Extending these existing systems to include resuscitated OHCA patients may facilitate improved neurologic outcomes among patients resuscitated from OHCA.
A relationship between case volume and outcome exists for other conditions requiring time-sensitive and critical interventions, and AHA recommends that level 1 cardiac resuscitation centers treat at least 40 patients resuscitated from OHCA annually. However, several prior studies evaluating the association between emergency department and hospital volumes of OHCA cases and survival yielded conflicting results, and we found no independent relationship between volume of admitted OHCA patients and good neurologic outcome. Unlike prior studies that included relatively few facilities with more than 40 OHCA patients per year, our data included 64 hospitals that admitted ≥40 patients resuscitated from OHCA with the highest-volume hospital admitting 149 patients in 1 year, allowing us to better evaluate the volume-outcome relationship at high-volume centers.
Treatment at a level 1–2 trauma center was associated with a trend toward lower odds of good neurologic recovery. This phenomenon may be due to OHCA patients competing with trauma patients for limited critical care resources, the urban environments where these centers are located, or other factors. Although this finding contrasts data from an Australian system in which the highest OHCA survival rates were seen at urban centers with cardiac and trauma designations, it aligns with a prior report that patients with potential acute coronary syndromes who presented to the emergency department concurrently with a trauma activation experienced worse outcomes than those who did not. These findings should be considered as regional systems of care that aggregate multiple specialty services within one hospital are developed.
Our data do not allow us to identify the processes contributing to better neurologic recovery at STEMI centers. Similar to prior studies, few patients in our population received cardiac catheterization or therapeutic hypothermia. Possible reasons for this low utilization include limited awareness of or agreement with the data supporting these interventions, perception of poor patient prognosis, lack of organized protocols, and concerns regarding cardiac catheterization outcome reporting. Recent data suggest that the therapeutic hypothermia target of 32 to 34°C recommended during the study period may be less beneficial than previously thought. Therapeutic hypothermia, cardiac catheterization, and percutaneous coronary intervention were all performed more frequently at STEMI centers than at non-STEMI centers. These procedures may contribute to the higher rates of good neurologic recovery seen at STEMI centers. Further investigation is required to characterize other processes of care at STEMI centers that contribute to these improved outcomes and that contribute to the variability in outcomes among STEMI centers.
Our study has several limitations. We were unable to control for prehospital arrest characteristics such as witnessed arrest, bystander interventions, and cardiopulmonary resuscitation quality, which are associated with good outcomes. We identified patients using a present on admission code for cardiac arrest and thus were unable to determine whether the cardiac arrest occurred in the prehospital or emergency department environment, although the overwhelming majority of cardiac arrests were likely prehospital. Furthermore, the number of unique patients we identified in the OHSPD database with a present on admission diagnosis of cardiac arrest or sudden cardiac death is consistent with the predicted number of OHCA cases with survival to hospital admission based on prior data. We used discharge disposition as a surrogate for good vs poor neurologic recovery. No neurological functional outcome measure has been well validated in post–cardiac arrest patients. Our classification aligns with the definitions of good neurologic recovery used in previous studies of post–cardiac arrest patients, and it correlates with the Cerebral Performance Category score. Because data were not available on all criteria in the AHA recommendations for cardiac resuscitation centers, we evaluated outcomes at STEMI that admitted ≥40 patients resuscitated from OHCA in 2011. Our prior data suggest that all of these hospitals had therapeutic hypothermia protocols in place by 2011, suggesting that they may meet AHA criteria for level 1 cardiac resuscitation centers.
Discussion
We found that treatment at an STEMI center after resuscitation from OHCA is associated with increased odds of good neurologic recovery. Our results are consistent with 2 smaller studies showing higher survival among resuscitated OHCA patients treated at hospitals with cardiac catheterization and with 2 larger studies showing higher survival among OHCA patients transported to at tertiary or critical care hospitals. These data suggest that patients resuscitated from OHCA would benefit from regionalized care at an STEMI center. Regionalized care improves processes of care in STEMI, trauma, stroke, and critical illness, and regionalized systems of care are well developed for patients with STEMI. Extending these existing systems to include resuscitated OHCA patients may facilitate improved neurologic outcomes among patients resuscitated from OHCA.
A relationship between case volume and outcome exists for other conditions requiring time-sensitive and critical interventions, and AHA recommends that level 1 cardiac resuscitation centers treat at least 40 patients resuscitated from OHCA annually. However, several prior studies evaluating the association between emergency department and hospital volumes of OHCA cases and survival yielded conflicting results, and we found no independent relationship between volume of admitted OHCA patients and good neurologic outcome. Unlike prior studies that included relatively few facilities with more than 40 OHCA patients per year, our data included 64 hospitals that admitted ≥40 patients resuscitated from OHCA with the highest-volume hospital admitting 149 patients in 1 year, allowing us to better evaluate the volume-outcome relationship at high-volume centers.
Treatment at a level 1–2 trauma center was associated with a trend toward lower odds of good neurologic recovery. This phenomenon may be due to OHCA patients competing with trauma patients for limited critical care resources, the urban environments where these centers are located, or other factors. Although this finding contrasts data from an Australian system in which the highest OHCA survival rates were seen at urban centers with cardiac and trauma designations, it aligns with a prior report that patients with potential acute coronary syndromes who presented to the emergency department concurrently with a trauma activation experienced worse outcomes than those who did not. These findings should be considered as regional systems of care that aggregate multiple specialty services within one hospital are developed.
Our data do not allow us to identify the processes contributing to better neurologic recovery at STEMI centers. Similar to prior studies, few patients in our population received cardiac catheterization or therapeutic hypothermia. Possible reasons for this low utilization include limited awareness of or agreement with the data supporting these interventions, perception of poor patient prognosis, lack of organized protocols, and concerns regarding cardiac catheterization outcome reporting. Recent data suggest that the therapeutic hypothermia target of 32 to 34°C recommended during the study period may be less beneficial than previously thought. Therapeutic hypothermia, cardiac catheterization, and percutaneous coronary intervention were all performed more frequently at STEMI centers than at non-STEMI centers. These procedures may contribute to the higher rates of good neurologic recovery seen at STEMI centers. Further investigation is required to characterize other processes of care at STEMI centers that contribute to these improved outcomes and that contribute to the variability in outcomes among STEMI centers.
Our study has several limitations. We were unable to control for prehospital arrest characteristics such as witnessed arrest, bystander interventions, and cardiopulmonary resuscitation quality, which are associated with good outcomes. We identified patients using a present on admission code for cardiac arrest and thus were unable to determine whether the cardiac arrest occurred in the prehospital or emergency department environment, although the overwhelming majority of cardiac arrests were likely prehospital. Furthermore, the number of unique patients we identified in the OHSPD database with a present on admission diagnosis of cardiac arrest or sudden cardiac death is consistent with the predicted number of OHCA cases with survival to hospital admission based on prior data. We used discharge disposition as a surrogate for good vs poor neurologic recovery. No neurological functional outcome measure has been well validated in post–cardiac arrest patients. Our classification aligns with the definitions of good neurologic recovery used in previous studies of post–cardiac arrest patients, and it correlates with the Cerebral Performance Category score. Because data were not available on all criteria in the AHA recommendations for cardiac resuscitation centers, we evaluated outcomes at STEMI that admitted ≥40 patients resuscitated from OHCA in 2011. Our prior data suggest that all of these hospitals had therapeutic hypothermia protocols in place by 2011, suggesting that they may meet AHA criteria for level 1 cardiac resuscitation centers.
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