Clinical paperDoes experience in prehospital post-resuscitation critical care affect outcomes? A retrospective cohort study
Introduction
During out-of-hospital cardiac arrest (OHCA) survival is dependent on the parts in the chain of survival.1 Timely, good quality cardiopulmonary resuscitation (CPR) and early defibrillation are crucial for a good outcome.1 Some studies have shown paramedics prior experience with OHCA to be associated with survival.2, 3 After return of spontaneous circulation (ROSC) the objectives of post-resuscitation care are to reverse any treatable cause for cardiac arrest and stabilize vital functions to prevent end organ damage.4, 5 The European Resuscitation Council (ERC) has published guidelines for post-resuscitation care,6 adherence to which has been associated with improved outcomes.7, 8
One main objective of Helicopter Emergency Medical Services (HEMS) are to concentrate advanced prehospital critical care, such as post-resuscitation care, to specialized teams. Centralizing care to cardiac arrest centers has been linked to better adherence to guidelines and improved survival.9, 10, 11 Physician-staffed HEMS units are rarely first on-scene, but work with ground-based EMS, units.12 Therefore, the emphasis of HEMS, is in post-resuscitation critical care.12 It is not yet clear, if the quality of this care depends on the physician's familiarity with pre-hospital post-resuscitation.12
It seems, that experience might be a factor affecting survival in cardiac arrest through the chain of survival. Due to this rational, OHCA is one of the most common missions for HEMS around the world.13, 14, 15, 16 We hypothesized that a physician with frequent experience in prehospital post-resuscitation care might achieve treatment goals, recommended by guidelines, more often and that this experience might be associated with better outcomes.
The aims of this study were to investigate whether a physician's exposure to prehospital post-resuscitation care in the previous 12 months was associated with: (1) differences in medical management, (2) how often treatment targets were achieved and (3) 30-day and 1-year survival.
Section snippets
Ethics approval
The Ethical Committee of Helsinki University Hospital approved the study protocol. Permissions to use patient data were applied and granted separately from each university hospital district (Oulu University Hospital 200/2019 2.7.2019, Helsinki University Hospital HUS/280/2019 9.7.2019, Turku University Hospital J30/19 4.8.2019, Hospital District of Lapland 32/2019 22.8.2019, Kuopio University Hospital RPL 102/2019 22.8.2019 and Tampere University Hospital RTL-R19580). The study did not affect
Results
During the study period 2 272 patients, treated by 91 physicians were analyzed (Fig. 1). Patient characteristics are presented in Table 1. A sustained ROSC was achieved in 1174 (52%) cases prior to HEMS arrival. For these, the median time from ROSC to HEMS arriving to scene was 9 (5–17) minutes. For the remainder ROSC was achieved in the presence of HEMS. 72 (3.2%) patients went into cardiac arrest while HEMS was already on scene. 30-day and 1-year follow up was completed for 2270 (99.9%) and
Discussion
We found that physicians with more, frequent, exposure to prehospital post-resuscitation care were more aggressive in initiating treatment and spent more time on-scene. In these cases, blood pressure treatment goals were achieved more often, but no association was seen in how often other treatment goals were achieved or in survival of the patients.
In our study almost half of the patients survived over a month, which is exceptional for a study of patients with OHCA.25 This is undoubtedly, in
Conclusions
Physicians with more, frequent exposure to prehospital post-resuscitation care treat patients more actively, but this does not seem to improve survival. The recommended physiological targets are met only in a moderate proportion of the cases.
Conflict of interest
None.
Credit author statement
AS was involved in conception of the study and contributed substantially to study design, did the primary analysis of the data and drafted the manuscript. HJ participated in the conception of the study and made important contributions to study design. She provided critical revisions to the manuscript providing important intellectual content. AH made substantial contributions in the analysis and interpretation of the data. He produced the figures for the manuscript with critical input from all
Acknowledgements
This study was funded by Helsinki University Hospital, Finland (state funding, VTR TYH2019243) and the FinnHEMS Research and Development Unit, Finland.
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