Systems Of Care Australian Cardiac Arrest Centres: What are we waiting for?
Systems Of Care Australian Cardiac Arrest Centres: What are we waiting for? Dr Dion Stub MBBS FRACP Cardiologist / Interventional Research Fellow Alfr...
Systems Of Care Australian Cardiac Arrest Centres: What are we waiting for? Dr Dion Stub MBBS FRACP Cardiologist / Interventional Research Fellow Alfred Hospital Baker IDI Heart and Diabetes Institute Monash University
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Outline
Clinical Case The post cardiac arrest syndrome Regional variation in cardiac arrest outcomes Potential impact of cardiac arrest centres Post cardiac care compliance Impact of bypassing hospitals and transport Issues
Punchy Advertising Campaign Push the Systems of Care in Cardiac Arrest Message
Australian Cardiac Arrest Centres....
Regional Systems of Care Improve Patient Outcomes “Bringing the right
patient, to the right place, to get the right care, at the right time”
Extreme A & E UK documentary regarding world’s leading trauma services
54year old male – no PHx Cycling in local rural town
Witnessed collapse – bystander calls 000 Bystander instructed to perform compression only CPR Arrest near local Shopping Centre Automated Defibrillator – delivers x 1 DCR Paramedics “...So which hospital is DC shocks x 6 – than asystole closest??” Endotracheal tube+ IV Adrenaline x 1mg IV every 4 minutes ROSC at 33 minutes post collapse Adrenaline infusion required to maintain BP Pre-Hospital Hypothermia (IV 30mL/kg ice saline)
Fundamentals of System of Care Chain of Survival
Early Access
Early CPR
Early Defib
Early Advanced Resus
Post Arrest Care
Case Cont Post Arrest - In hospital Care • Arrives in sinus rhythm escalating doses of adrenaline • Temperature 34 in Emergency Department • Hospital staff concerned with role of therapeutic hypothermia in shock – cease cooling patient.... • Coronary Cath Lab not open on weekends In Emergency Department • Ph – 7.1 • Fixed Dilated Pupils • ECG – Diffuse ST depression • Call through to Metropolitan PCI Centre....
“Struggling with ICU beds” “Guarded Prognosis” “Not a STEMI no rush Cath” “Call us if he wakes up” “Then we are more than happy to look after him.....”
•Patient Develops worsening cardiogenic shock •Multi-organ failure •Acute Retrieval Service called at 24 hours – ? too sick for transport •Patient deceased 36 hours after admission
Challenges of Cardiac Arrest 1. 2. 3. 4.
35,000 sudden cardiac deaths in Australia per year In up to 50% of patients - cardiac arrest will be patient’s first ‘cardiac’ symptom Only 20% of people can be revived and transported to hospital Of these only 30% of patients survive to be sent home
Sasson C etal Circulation Quality 2009
Post Cardiac Arrest Syndrome Time to Update our Philosophy “The Die is cast” “ Terrible Prognosis” “Delaying inevitable” Stub, Bernard, et al Circulation 2011
Potential influence of Hospital Care “Post-resuscitation care is key to improving the proportion that not only survive long term, but also survive with favourable neurological function.” Kern JACC I 2012
Optimising Post Resus Care
Peberdy et al Circ 2010 AHA Guidelines
Towards a Regional System of Care in Out of Hospital Cardiac Arrest 1) Is there a difference in outcomes across Regions and institutions? 2) What Hospital Factors Are important? 3) Does Standardising Post Resus Care improve outcomes? 4) What is impact of prolonging transport? 5) Can all ICU’s in Australia provide optimal Post resus Care?
Are Hospital Factors Associated with Patient outcomes?
• Swedish Registry of OHCA • 3850 patients • Adjusted 30 day survival varied between hospital 14% - 42% • No details of actual postresuscitative Care
Herlitz et al Resus 2006
What Hospital Factors Are Important? USA NIS database 100,000 patients Improved Outcomes post Cardiac Arrest: • Larger Hospitals • Urban Hospitals • Teaching Hospitals
Carr et al Intensive Care Med 2009
Unclear which hospital characteristics are most important Cardiac Arrest Registry to Enhance Survival database (CARES) Conclusions • Survival varied substantially across hospitals. Not Volume or Cath Lab volume • However, hospital OHCA was not associated with likelihood of survival. • Additional efforts are required to determine what hospital characteristics might account for the variability Cudnik et al Resus 2012
What is Influence of PCI centre Resuscitation Outcomes Consortium 400 patients 254 Hospitals Conclusions • Patients who were treated at hospitals capable of invasive cardiac procedures and hospitals that treat a large volume of cardiac arrest patients had increased rates of survival. • However, there was no independent effects of hospital characteristics...
Callaway et al Resus 2010
Australian Data • Analyzed data from the Victorian Ambulance Cardiac Arrest Registry (VACAR) of patients from January 2003 to March 2010 who were transported to hospital with return of spontaneous circulation after OHCA. • Examined receiving hospital characteristics such as 24 hour cardiac catheterisation services, total bed number or OHCA patient volume influence the rate of survival Stub, Smith, Bray, Bernard et al Heart 2011
Is it PCI Capabilities or Something More?
Stub et al Heart 2011
Evidence for implementation of Regional Systems of Care in OHCA
Lick et al Crit Care Med 2011 – Minnesota System Care
Adding Cardiac Arrest Protocols to Pre-existing STEMI Networks Minneapolis Level 1 Heart Attack Program – STEMI transfers
142 Patient Pilot Study 56% Survival to hospital discharge 92% good neurological outcome Significant Improvement in use of Hypothermia
“Cool It” Program regional TH system Feb 2006 Mooney et al Circ 2011
Stub et al American Journal Cardiol 2011
Aims: •To compare outcomes in patients resuscitated from OHCA pre and post introduction of post arrest protocol. Methods: • Retrospective review at major trauma and cardiac receiving centre •125 patients admitted post OHCA with VF/VT. • Survival to hospital discharge and neurologic recovery were compared in two treatment periods 2002-2003 and 2007-2009.
Contemporary Management of OHCA Multivariate Predictors of Survival Cardiogenic Shock ROSC > 20 mins Unconscious
“We would call for urgent research into the efficacy and implications of establishing a regional system of care for patients post-OHCA in Australia.” Stub, Bernard, Smith et al Internal Med Journ 2012
1. 2.
Editorial Questioning Relevance in Australian Population
“Transferring patients over long distances..... cannot be recommended” “Evidence based management of patients following OHCA is fairly straightforward for the majority of patients and should be possible in most ICUs” O’Leary IMJ 2012
What is Impact of Longer Transport Time?
The overall mean difference in transport distance in patients taken to the further hospital compared to the closest hospital was 1.70 miles (2.74 km).
Cudnik et al Resus 2010
What is Quality of Post Resus Care in Australian Hospitals? Boyce et al Aust Crit Care 2012 • Single centre 12 month review of cooling post cardiac arrest. • Major Brisbane Metro Hospital • 12% of patients at target temp by 2 hrs. • Only 27% patients cooled for 24 hrs • 33% of patients not cooled at all
Documented temperature in the ICU.
Therapeutic hypothermia following out-of-hospital cardiac arrest (OHCA): an audit of compliance at a large Australian hospital McGloughlin et al Anaes Int Care 2012
Single Centre Retrospective Review Another Major Brisbane centre TH in Comatose survivors VF arrest Only 20% patients commenced TH in emergency department • On average 9 hours to reach target temperature • • • •
Issues also concerning utilisation of Coronary Angiography
Merchant et al Resus 2008 • Single Chicago Centre Review of 110 patients with VF arrest • Only 27% of patients received coronary angiography within 24 hours
Lim H, Stub D et al IJC 2011 • •
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Review of patients with OHCA undergoing in 8 Melbourne centres 558 patients brought to the study hospitals with OHCA during study period (VACAR database) Only 20% undergoing PCI Possibility of underutilization of coronary angiography in post resus management
Case 2 37 year old male – no PHx Ex smoker – Fit and Active
Witnessed collapse – 1900 - bystander calls 000 “F!*%” No bystander CPR Patient in RINSE trial. Wish I could put them in Fire Brigade respond < 5minutes CHEER study...not after hours Automated Defibrillator – delivers x 2 DCR What now? Paramedics Should we Stop??? DC shocks x 2 into PEA rhythm Endotracheal tube+ IV Adrenaline x 1mg IV every 4 minutes Intra-Arrest Hypothermia (IV 30mL/kg ice saline) 45 minutes of manual CPR – now asystole
Case 2 Cont MICA continued Resuscitation • Automated CPR Device applied • Ongoing CPR for further 30 minutes • ROSC obtained at 75 minutes post collapse Transported to nearby Cardiac Centre In Emergency Department • Temperature 33 • Ph – 6.8 Lactate 12.4 • Fixed Dilated Pupils • ECG – Anterior STEMI
“No early Prognostication” “Cool, Cath, Comprehensive Post Arrest care”
Case 2 Post Resuscitative Care Emergent: • Aspirin/ Clopidogrel/Heparin • Sedation/Paralysis • Cont Therapeutic Hypothermia – 24 hours • Coronary Angiogram – Occluded Proximal LAD – PCI BMS x2 • Haemodynamic Support – Adrenaline converted to Dobutamine and Norad
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TTE – LV mod severe dysfunction Extubated Day 2 Transferred to ward day 5 Initial Delirium improved Escalation of Medical therapy –
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Metop XL /Perindopril/Eplerenone
Social Work Review Discussion regarding need for AICD – Consideration of Life Vest Discharged Home Day 9
Nichol et al Circulation 2010
“.... Many more people could potentially survive out-ofhospital cardiac arrest if regional systems of cardiac resuscitation were established.” “A national process is necessary to develop and implement evidence-based guidelines for such systems that must include standards for the categorization, verification, and designation of components of such systems.” “The time to do so is now”
Issues • Urgent need for detailed collection of post arrest care to compliment pre-hospital Australian Cardiac arrest registries • Further research into which model will work with issues of population and distance in Australia • Integration with STEMI network / State-wide Trauma models • Issues of patient selection – Should we consider for all patients with OHCA or limit to patients with shockable rhythms, age criteria etc?
Acknowledgements Alfred Hospital • David Kaye • Stephen Bernard • Stephen Duffy • James Shaw • Vin Pellegrino
Ambulance Victoria • Karen Smith • Michael Stephenson • Ziad Nehme • Janet Bray
Baker IDI Research Supported by: • Heart Foundation Scholarship • Melissa Byrne • Heart Failure Research Group • Baker IDI Bright Sparks Award • Australian Cardiac Society Scholarship
