Elsevier

Resuscitation

Volume 145, December 2019, Pages 50-55
Resuscitation

Clinical paper
The effects of route of admission to a percutaneous coronary intervention centre among patients with out-of-hospital cardiac arrest

https://doi.org/10.1016/j.resuscitation.2019.09.032Get rights and content

Abstract

Aim

Patients with OHCA who are not transported directly to a percutaneous coronary intervention (PCI)-capable hospital may eventually undergo an inter-hospital transfer (IHT). The aim of the present study was to investigate the effects of route of admission to a PCI centre among patients with OHCA.

Methods

We included patients with OHCA of presumed cardiac aetiology that were admitted to a PCI centre between January 2015 and December 2016. The exposure variable was route of admission: direct versus indirect. The ‘direct’ group was defined as patients who were transferred directly from the field to a PCI centre by emergency medical service (EMS) providers. The ‘indirect’ group was defined as patients who underwent IHT from a non-PCI centre to a PCI centre. The primary outcome was neurological recovery. We evaluated the effects of route of admission using multivariable logistic regression analysis after adjusting for potential confounders.

Results

There were total of 4363 eligible patients: 3488 (78.2%) in the direct group and 975 (21.8%) in the indirect group. Neurologic recovery was better in the direct group (38.0%) than in the indirect group (29.0%). After adjusting for potential confounders, indirect admission was negatively associated with outcomes (adjusted odds ratio [aOR] 0.70; 95% confidence interval [CI] 0.58–0.85).

Conclusions

The route of admission to a PCI centre is associated with neurological recovery among resuscitated patients with OHCA of presumed cardiac aetiology. This has implications for regionalized EMS transport and IHT protocols for patients with OHCA.

Introduction

Out-of-hospital cardiac arrest (OHCA) is a major health problem because of its increasing incidence and high fatality rate.1 A recent meta-analysis reported that the annual incidence of OHCA per 100,000 people was 54.6 in North America, 35.0 in Europe, and 28.3 in Asia.2 Survival and neurological outcomes remain notoriously dismal (6%–9%) and are subject to regional variation.3, 4

Regionalization of care is recommended to improve outcomes for patients with OHCA, as well as patients with ST-segment elevation myocardial infarction (STEMI) and trauma.5 The 2015 American Heart Association guidelines recommend direct transport to a specialized cardiac resuscitation centre (CRC) for patients with OHCA.6 The capability to deliver emergency percutaneous coronary intervention (PCI) is crucial for CRCs. Recently, several studies have reported that direct transport to PCI-capable hospitals is associated with better outcomes, not only for STEMI patients, but among OHCA patients in general.7, 8, 9

Although the international consensus is that direct transport to a PCI-capable hospital is desirable, in some regions emergency medical service (EMS) providers transport OHCA patients to the nearest hospital because of non-regionalized protocols.7, 10 Patients with OHCA who are not transported directly to a PCI-capable hospital may eventually undergo an inter-hospital transfer (IHT). Several previous studies have reported adverse outcomes among transferred patients with OHCA.7, 11 However, these studies were conducted in single centres or within a single geographic region. Here, we report our findings based on analysis of a national OHCA database, which encompasses multiple regions.

The objective of this study was to compare outcomes between patients who were directly transported to PCI-capable hospitals and those who underwent IHT. We hypothesized that there would be no significant differences in outcomes according to the route of admission among patients with OHCA.

Section snippets

Study setting

The Korean EMS is a multi-tiered system for patients with OHCA and is operated by fire departments.12 According to the national pre-hospital protocol; EMS providers should transport patients with OHCA to the nearest emergency department (ED), regardless of the PCI capacity of the receiving hospital. However, there are no regional CRCs in Korea. The majority of community hospitals do not have protocols for IHT of OHCA patients. Mobile intensive units (MICUs) for IHT have been adopted in only one

Results

Of the 36,259 EMS-assessed adults with presumed cardiac-origin OHCA during the study period, 44.7% were directly transported to PCI-capable hospitals. Among these patients, 3488 (21.5%) were admitted to a hospital. Among patients who were initially transported to non-PCI-capable hospitals, 975 (6.4%) were transferred to a PCI-capable hospital. A total of 4463 eligible patients were thus admitted to PCI-capable hospitals, excluding patients who were transferred from PCI-capable hospitals or from

Discussion

This nationwide study of OHCA cases with presumed cardiac origin found that direct EMS transport to a PCI-capable hospital was associated with improved neurological recovery and survival to discharge compared with transfer via non-PCI-capable hospitals. This association remained significant across the subgroup of patients who achieved ROSC on scene.

The indirect group had poorer outcomes compared with the direct group, even after adjustment for potential cofounders. There are several possible

Conclusions

Direct transport to a PCI-capable hospital is associated with outcome benefit for patients with OHCA. This has implications for regionalized EMS transport and IHT protocols for patients with OHCA.

Financial support

This study was financially supported by the Korea Centers for Disease Control and Prevention (CDC). Grant number [2009-E00543-00, 2010-E33022-00, 2011-E33004-00, 2012-E33010-00, 2013-E33015-00, 2014-E33011-00].

Conflict of interest

All authors report no conflicts of interest.

Contributorship statement

  • (1)

    The conception and design of the study, or analysis and interpretation of data: Dr. Suh, and Dr. Ahn.

  • (2)

    Drafting the article or revising it critically for important intellectual content: Dr. Suh and Dr. Ahn.

  • (3)

    Acquisition of data and Obtained funding: Dr. Shin.

  • (4)

    Final approval of the version to be submitted: All authors.

References (25)

Cited by (2)

  • Association between health insurance status and transfer of patients with return of spontaneous circulation after out-of-hospital cardiac arrest

    2020, Resuscitation
    Citation Excerpt :

    Mobile intensive units for inter-hospital transfer have been adopted in only one metropolitan region (Seoul) in the Republic of Korea since 2016.18 In a previous study in the Republic of Korea, more than an hour elapsed before transfer to a heart attack centre for >20% of patients.19 This cross-sectional observational study used data from a Korean national EMS-assessed OHCA registry.

View full text