Cardiac Arrest Centers: EIT 6301 TF SR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: Matsuyama

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: None declared

CoSTR Citation

Yeung J, Abelairas-Gomez, Boulton A, Olaussen A, Skrifvars M, Greif R on behalf of the International Liaison Committee on Resuscitation (ILCOR) Education, Implementation and Team (EIT) Task Force.

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with systematic review triggered by the EIT Task Force in 2019 (1) (PROSPERO CRD42018093369). Evidence for adult and pediatric literature was sought and considered by the EIT Task Force. 2023 Search strategy (Appendix A) was reviewed and updated by Samantha Johnson, Information specialist at University of Warwick. Additional scientific literature was published after the completion of the systematic review and identified by the EIT Task Force and is described before the justifications and evidence to decision highlights section of this CoSTR. These data were taken into account when formulating the Treatment Recommendations.

Systematic Review

Webmaster to insert the Systematic Review citation and link to Pubmed using this format when it is available if published

PICOST

PROSPERO Registration CRD42018093369

Background

There is wide variability in survival among hospitals caring for patients after resuscitation from out of hospital cardiac arrest (OHCA). Regionalisation of care into specialist centers has played a vital role in the management of time-critical illnesses through concentration of services and greater provider experience (e.g. trauma, stroke services). The adoption of specialised post-cardiac arrest care at a cardiac arrest center (CAC) may improve long-term survival from OHCA. Previous studies have reported an association between survival to hospital discharge and transport to CAC but there is inconsistency in the hospital factors that are most related to patient outcome.(1)

The International Liaison Committee on Resuscitation (ILCOR) last considered the evidence in 2020 and concluded that specialist CAC may be effective despite a lack of high-quality data to support its implementation.(2) Since this review, new data examining the impact of CAC has been published and this updated PICOST will review and update the evidence base.

Definition of Cardiac arrest center/CAC:

Cardiac arrest centers are defined by the Association for Acute Cardio-Vascular Care of the European Society of Cardiology as specialized institutions offering all recommended treatment options for patients with OHCA, including access to a coronary angiography laboratory with 24/7 PCI capability, targeted temperature measurement (TTM), extracorporeal membrane oxygenation, mechanical ventilation, and neurological prognostication.(3) We adopted a strict definition of CAC, only institutions with the capability for 2 or more of the above interventions and explicitly referred to by study authors as CACs (or synonymous terms such as critical care medical center, tertiary heart center, regional center) were accepted.(4) We excluded studies which used high volume (number of cases/patients) or PCI capability as the only distinguishing characteristics.

Consensus on Science

Sixteen studies were included in our review (Figure 1, Table 1).(5-20) Risk of bias assessment can be found in Table 2a & b.

For the critical outcome 1 of survival to 30 days with favorable neurological outcomes, we identified very low certainty evidence (downgraded for risk of bias, inconsistency and imprecision) from 2 observational studies (evaluating over 40000 patients) that showed improved outcomes. (6, 7) One RCT which evaluated only patients post-non-STEMI was excluded from analysis.(5) , Because of a high degree of heterogeneity, no meta-analysis could be performed (Figure 2).

For the critical outcome 2 hospital discharge with favorable neurological outcomes, we identified very low certainty evidence (downgraded for risk of bias, inconsistency and imprecision) from 9 observational studies (evaluating over 110000 patients) that showed improved outcomes. (6, 8-15). One RCT which evaluated only patients post-non-STEMI was excluded from analysis.(5) Because of a high degree of heterogeneity, no meta-analyses could be performed (Figure 3).

For the critical outcome 3 survival to 30 days, we identified very low certainty evidence (downgraded for risk of bias, inconsistency and imprecision) from 2 observational studies (evaluating over 40000 patients) that showed improved outcomes. (7, 11) One RCT which evaluated only patients post-non-STEMI was excluded from analysis.(5) Because of a high degree of heterogeneity, no meta-analyses could be performed (Figure 4).

For the critical outcome 4 of survival to hospital discharge, we identified very low certainty evidence (downgraded for risk of bias, inconsistency and imprecision) from 11 observational studies (evaluating over 110000 patients) that showed improved outcomes.(6, 8-17) Because of a high degree of heterogeneity, no meta-analysis could be performed (Figure 5).

For the important outcome of return of spontaneous circulation, we identified very low certainty evidence (downgraded for risk of bias, inconsistency and imprecision) from 3 observational studies (evaluating over 50000 patients) that showed improved outcomes. (7, 9, 16) Because of a high degree of heterogeneity, no meta-analysis could be performed (Figure 6).

Treatment Recommendations

We suggest adults with OHCA should be cared for in cardiac arrest centers (weak recommendation, very-low certainty evidence).

Justification and Evidence to Decision Framework Highlights

In making this suggestion, the EIT taskforce considered the following:

• This topic was prioritized by the EIT Task Force based on ongoing interest in improving patient outcomes following OHCA.

• We defined a cardiac arrest centers as specialized institutions offering two or more recommended treatment options for patients with OHCA, including access to a coronary angiography laboratory with 24/7 PCI capability, TTM, extracorporeal membrane oxygenation, mechanical ventilation, and neurological prognosticationcardiac arrest centre as those providing target temperature management and cardiac invention.

• Expedited transfer to a cardiac arrest centre for non-ST-elevation out-of-hospital cardiac arrest (ARREST) trial was published in 2023.(5) The results did not show any benefits in patients transferred to CAC. Based on their results, we are unable to recommend for or against transferring OHCA adults with presumed cardiac cause presenting with non-STEMI with prehospital ROSC to a CAC, as this RCT was in a very specific urban city setting.
• Given the lack of generalisability, we included published data from non-randomised studies in our review.

• We considered the successful implementation of regionalized care for trauma, stroke and STEMI with improved outcomes.

• We reflected on the high level of resources required, particularly in regions with no regionalized emergency transport in place for other conditions (e.g. trauma, stroke, STEMI) and concluded that the benefits potentially outweigh issues associated with implementation of CAC.

• We recognised that implementing this recommendation may be resource and cost intensive, and whilst it has been successfully implemented in some countries, it may not be feasible in all regions.

• There was insufficient data for subgroup analyses to make any recommendations about specific subgroups including age group, presenting rhythm, primary versus secondary transfer, except from one RCT in a very specific setting.

• We did not identify any studies on pediatric patients or in-hospital cardiac arrest in this review.

Knowledge Gaps

• There were no studies identified that evaluated this question in the pediatric and in-hospital setting.
• Most studies only reported short term outcomes until hospital discharge, future studies should document long term neurological intact survival.
• There was a lack of studies that evaluated the long-term benefits and the impact on patient reported outcomes (21)
• There were insufficient data to allow for evaluating the effect of care at CAC in specific subgroups (e.g. age, cardiac aetiology, shockable or no-shockable rhythm)
• There were no studies that reported on the cost-effectiveness of transferring and or caring for patients at cardiac arrest centers
• There were no studies that evaluated any negative outcomes associated with bypassing nearest hospitals (e.g. de-skilling in post-arrest management) and transferring patients to cardiac arrest centers
• There is insufficient evidence to evaluate what is a safe distance or time for transport
• There were no studies that examined the impact on families, particularly those from remote regions.
• There were no studies that evaluated the potential impact on organ donation.
• There is insufficient data from large RCT including a broad variety of populations and aetiology of CA, as all studies but one are observational trials.

Attachments: EIT 6301 Cardiac Arrest Centers Et D, EIT 6301 Fig 1 PRISMA, EIT 6301 Cardiac Arrest Centers Table 2a b ROB, EIT 6301 GRADE table, EIT 6301 Table 1 Characteristics of included studies

References

1. Yeung J, Matsuyama T, Bray J, Reynolds J, Skrifvars MB. Does care at a cardiac arrest centre improve outcome after out-of-hospital cardiac arrest? - A systematic review. Resuscitation. 2019;137:102-15.

2. Soar J, Berg KM, Andersen LW, Bottiger BW, Cacciola S, Callaway CW, et al. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2020;156:A80-A119.

3. Sinning C, Ahrens I, Cariou A, Beygui F, Lamhaut L, Halvorsen S, et al. The cardiac arrest centre for the treatment of sudden cardiac arrest due to presumed cardiac cause – aims, function and structure: Position paper of the Association for Acute CardioVascular Care of the European Society of Cardiology (AVCV), European Association of Percutaneous Coronary Interventions (EAPCI), European Heart Rhythm Association (EHRA), European Resuscitation Council (ERC), European Society for Emergency Medicine (EUSEM) and European Society of Intensive Care Medicine (ESICM). European Heart Journal Acute Cardiovascular Care. 2020;9(4_suppl):S193-S202.

4. Yeo JW, Ng ZHC, Goh AXC, Gao JF, Liu N, Lam SWS, et al. Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out‐of‐Hospital Cardiac Arrest: A Systematic Review and Meta‐Analysis. Journal of the American Heart Association. 2022;11(1):e023806.

5. Patterson T, Perkins GD, Perkins A, Clayton T, Evans R, Dodd M, et al. Expedited transfer to a cardiac arrest centre for non-ST-elevation out-of-hospital cardiac arrest (ARREST): a UK prospective, multicentre, parallel, randomised clinical trial. Lancet. 2023;402(10410):1329-37.

6. Tagami T, Hirata K, Takeshige T, Matsui J, Takinami M, Satake M, et al. Implementation of the fifth link of the chain of survival concept for out-of-hospital cardiac arrest. Circulation. 2012;126(5):589-97.

7. Matsuyama T, Kiyohara K, Kitamura T, Nishiyama C, Nishiuchi T, Hayashi Y, et al. Hospital characteristics and favourable neurological outcome among patients with out-of-hospital cardiac arrest in Osaka, Japan. Resuscitation. 2017;110:146-53.

8. Jung E, Ro YS, Park JH, Ryu HH, Shin SD. Direct Transport to Cardiac Arrest Center and Survival Outcomes after Out-of-Hospital Cardiac Arrest by Urbanization Level. Journal of clinical medicine. 2022;11(4).

9. Kim JY, Moon S, Park JH, Cho HJ, Song JH, Jeon W, et al. Effect of transported hospital resources on neurologic outcome after out-of-hospital cardiac arrest. Signa Vitae. 2019;15(1):51-8.

10. Kragholm K, Malta Hansen C, Dupre ME, Xian Y, Strauss B, Tyson C, et al. Direct Transport to a Percutaneous Cardiac Intervention Center and Outcomes in Patients With Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes. 2017;10(6).

11. McKenzie N, Williams TA, Ho KM, Inoue M, Bailey P, Celenza A, et al. Direct transport to a PCI-capable hospital is associated with improved survival after adult out-of-hospital cardiac arrest of medical aetiology. Resuscitation. 2018;128:76-82.

12. Soholm H, Kjaergaard J, Bro-Jeppesen J, Hartvig-Thomsen J, Lippert F, Kober L, et al. Prognostic Implications of Level-of-Care at Tertiary Heart Centers Compared With Other Hospitals After Resuscitation From Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes. 2015;8(3):268-76.

13. Spaite DW, Bobrow BJ, Stolz U, Berg RA, Sanders AB, Kern KB, et al. Statewide regionalization of postarrest care for out-of-hospital cardiac arrest: association with survival and neurologic outcome. Ann Emerg Med. 2014;64(5):496-506 e1.

14. Sunde K, Pytte M, Jacobsen D, Mangschau A, Jensen LP, Smedsrud C, et al. Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation. 2007;73(1):29-39.

15. Yeh C-C, Chang C-H, Seak C-J, Chen C-B, Weng Y-M, Lin C-C, et al. Survival analysis in out-of-hospital cardiac arrest patients with shockable rhythm directly transport to Heart Centers. Signa Vitae. 2021;17(5):95-102.

16. Cournoyer A, Notebaert É, de Montigny L, Ross D, Cossette S, Londei-Leduc L, et al. Impact of the direct transfer to percutaneous coronary intervention-capable hospitals on survival to hospital discharge for patients with out-of-hospital cardiac arrest. Resuscitation. 2018;125:28-33.

17. Stub D, Smith K, Bray JE, Bernard S, Duffy SJ, Kaye DM. Hospital characteristics are associated with patient outcomes following out-of-hospital cardiac arrest. Heart. 2011;97(18):1489-94.

18. Mumma BE, Diercks DB, Wilson MD, Holmes JF. Association between treatment at an ST-segment elevation myocardial infarction center and neurologic recovery after out-of-hospital cardiac arrest. American Heart Journal. 2015;170(3):516-23.

19. Chien C-Y, Tsai S-L, Tsai L-H, Chen C-B, Seak C-J, Weng Y-M, et al. Impact of Transport Time and Cardiac Arrest Centers on the Neurological Outcome After Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Study. Journal of the American Heart Association. 2020;9(11):e015544.

20. Chocron R, Bougouin W, Beganton F, Juvin P, Loeb T, Adnet F, et al. Are characteristics of hospitals associated with outcome after cardiac arrest? Insights from the Great Paris registry. Resuscitation. 2017;118:63-9.

21. Haywood K, Whitehead L, Nadkarni VM, Achana F, Beesems S, Böttiger BW, et al. COSCA (Core Outcome Set for Cardiac Arrest) in Adults: An Advisory Statement From the International Liaison Committee on Resuscitation. Circulation. 2018;137(22):e783-e801.

Appendix A. Search strategy

Ovid MEDLINE(R) <1946 to 23/06/2023>

[“Cardiac Care Facilities/” OR “Cardiology Service, Hospital/” OR “Regional Medical Programs/” OR (Heart attack Centre* or Heart Attack Center* or cardiac arrest centre* or cardiac arrest center*).ab,kf,ti.OR fifth link.ab,kf,ti. OR (cardiac resuscitation center* or cardiac resuscitation centre* or regional cardiac resuscitation).ab,kf,ti. OR (CRC or CRC*).ab,kf,ti. OR (regional system* or network or hospital volume or patient volume).ab,kf,ti. OR (Cardiac Receiving Center* or Cardiac Receiving Centre*).ab,kf,ti. OR (post cardiac arrest adj1 (care or treatment)).ab,kf,ti. OR (postcardiac arrest adj1 (care or treatment)).ab,kf,ti. OR (post resuscitation adj1 (care or treatment)).ab,kf,ti. OR (postresuscitation adj1 (care or treatment)).ab,kf,ti. OR "Cardiac Care Facilit*".ab,kf,ti. OR (Cardiac adj2 (Centre* or Center*)).ab,kf,ti. OR (Cardiology adj1 (Service or care) adj2 Hospital).ab,kf,ti. OR (Cardiovascular adj1 (Centre or Center)).ab,kf,ti. OR cardiac catheterisation laboratory.ab,kf,ti. OR (CAC or CACs).ab,kf,ti. OR Tertiary Care Centers/ OR (Tertiary adj1 (care or Center* or Centre*)).ab,kf,ti. OR Cardiac Arrest Registry.ab,kf,ti. OR ("Critical care medical center*" or "Critical care medical centre*").ab,kf,ti. OR ("critical care centre*" or "critical care center*").ab,kf,ti.] AND [heart arrest/ or out-of-hospital cardiac arrest/ OR cardiopulmonary resuscitation/ or advanced cardiac life support/ OR Death, Sudden, Cardiac/ OR Out of Hospital Cardiac Arrest.ab,kf,ti. OR OHCA.ab,kf,ti. OR return of spontaneous circulation.ab,kf,ti.OR ROSC.ab,kf,ti. OR ((heart or cardiac or cardiovascular) adj1 arrest).ab,kf,ti. OR asystole.ab,kf,ti. OR pulseless electrical activity.ab,kf,ti. OR Advanced Cardiac Life Support.ab,kf,ti. OR ACLS.ab,kf,ti. OR Ventricular Fibrillation/ OR (cardiopulmonary arrest or cardiopulmonary resuscitation).ab,kf,ti. OR (Cardio-pulmonary arrest or cardio-pulmonary resuscitation or CPR).ab,kf,ti. OR code blue.ab,kf,ti.] NOT OR Animals/ not (Animals/ and Humans/) OR (letter or comment or editorial).pt.]

Embase <1947 to 23/06/2023>

[heart center/ OR cardiology service/ OR "Regional Medical Program*".ab,hw,ti. OR (Heart attack Centre* or Heart Attack Center* or cardiac arrest centre* or cardiac arrest center*).ab,hw,ti. OR "Cardiology Service*".ab,hw,ti. OR fifth link.ab,hw,ti. OR (cardiac resuscitation center* or cardiac resuscitation centre* or regional cardiac resuscitation).ab,hw,ti.

OR (CRC or CRC*).ab,hw,ti. OR (regional system* or network or hospital volume or patient volume).ab,hw,ti.OR (Cardiac Receiving Center* or Cardiac Receiving Centre*).ab,hw,ti. OR (post cardiac arrest adj1 (care or treatment)).ab,hw,ti. OR (postcardiac arrest adj1 (care or treatment)).ab,hw,ti. OR (post resuscitation adj1 (care or treatment)).ab,hw,ti. OR (postresuscitation adj1 (care or treatment)).ab,hw,ti. OR "Cardiac Care Facilit* ".ab,hw,ti. OR (Cardiac adj2 (Centre* or Center*)).ab,hw,ti. OR (Cardiology adj1 (Service or care) adj2 Hospital).ab,hw,ti. OR (Cardiovascular adj1 (Centre or Center)).ab,hw,ti. OR cardiac catheterisation laboratory.ab,hw,ti. OR (CAC or CACs).ab,hw,ti. OR tertiary care center/ OR (Tertiary adj1 (care or Center* or Centre*)).ab,hw,ti. OR Cardiac Arrest Registry.ab,hw,ti. OR ("Critical care medical center*" or "Critical care medical centre*").ab,hw,ti. OR ("critical care centre*" or "critical care center*").ab,hw,ti.] AND [heart arrest/ or cardiopulmonary arrest/ or "out of hospital cardiac arrest"/ or sudden cardiac death/ OR cardiac life support.ab,hw,ti. OR OHCA.ab,hw,ti. OR "return of spontaneous circulation"/ OR ((heart or cardiac or cardiovascular) adj1 arrest).ab,hw,ti. OR asystole.ab,hw,ti. OR pulseless electrical activity.ab,hw,ti. OR ACLS.ab,hw,ti. OR heart ventricle fibrillation/ OR (cardiopulmonary arrest or cardiopulmonary resuscitation).ab,hw,ti. OR (Cardio-pulmonary arrest or cardio-pulmonary resuscitation or CPR).ab,hw,ti. OR code blue.ab,hw,ti.] NOT (Conference abstract or conference paper or conference review or book or editorial or letter).pt.]

Cochrane <search date 23/06/2023>

[MeSH [Cardiac Care Facilities] exp OR MeSH [Cardiology Service, Hospital] exp OR (Heart attack Centre* or Heart Attack Center* or cardiac arrest centre* or cardiac arrest center*):ti,kw,ab OR MeSH: [Regional Medical Programs] exp OR ("fifth link"):ti,kw,ab OR (cardiac resuscitation center* or cardiac resuscitation centre* or regional cardiac resuscitation):ti,kw,ab OR (regional system* or network or hospital volume or patient volume or Cardiac Receiving Center* or Cardiac Receiving Centre*):ti,kw,ab OR ("post cardiac arrest care" or "post cardiac arrest treatment"):ti,kw,ab OR (postcardiac arrest care or postcardiac arrest treatment):ti,kw,ab OR ("post resuscitation care" or "post resuscitation treatment"):ti,kw,ab OR (postresuscitation care or postresuscitation treatment):ti,kw,ab OR (Cardiac Care Facilit*):ti,kw,ab OR (Cardiac centre* or Cardiac center*):ti,kw,ab OR (Cardiovascular centre* or Cardiovascular center*):ti,kw,ab OR (cardiac catheterisation laboratory):ti,kw,ab OR MeSH: [Tertiary Care Centers] exp OR (Tertiary care or Tertiary center* or Tertiary centre*):ti,kw,ab OR (Cardiac Arrest Registry):ti,kw,ab OR (Critical care medical center* or Critical care medical centre* or critical care centre* or critical care center*):ti,kw,ab] AND [MeSH: [Heart Arrest] exp OR MeSH: [Cardiopulmonary Resuscitation] exp OR (Hospital Cardiac Arrest or OHCA or return of spontaneous circulation or ROSC or asystole):ti,kw,ab OR ("heart arrest" or "cardiac arrest" or "cardiovascular arrest"):ti,kw,ab OR (pulseless electrical activity or cardiopulmonary arrest or cardiopulmonary resuscitation or Cardio-pulmonary arrest or cardio-pulmonary resuscitation or CPR or ACLS):ti,kw,ab OR MeSH: [Ventricular Fibrillation] exp]