Several systems have successfully incorporated therapeutic hypothermia into their resuscitation efforts as part of many significant efforts made in recent years to improve cardiac arrest outcomes. But across the country, the use of hypothermia has not yet become an accepted standard; regionalization of cardiac arrest management remains the subject of discussions in the literature.(1–5)
In 2008, the New York City 9-1-1 System provided nearly 1.4 million EMS responses, including 7,357 cardiac arrest patients for whom resuscitation was attempted. As a result of advancements in cardiac arrest care, these patients were more likely to achieve return of spontaneous circulation (ROSC) than ever before, including a 75% increase in ROSC among witnessed arrests of cardiac etiology.
But the lack of a regional approach to cardiac arrest management meant that patients were transported to all 68 hospitals within the five boroughs of New York City, few of which were actively utilizing hypothermia, and even fewer of which had protocols recommending its use for a wide range of patients.
From Need to Reality
In late 2007, FDNY led discussions to facilitate the development of a system for regionalized cardiac arrest care. These initial meetings were inclusive, allowing the participation of any interested hospital with the goal of ensuring the incorporation of therapeutic hypothermia as a regional standard for post-resuscitation management. Hospitals interested in becoming Cardiac Arrest Centers needed to meet the following qualifications:
Over the next 12 months, FDNY joined with NYC Health and Hospitals Corporation and the Greater New York Hospital Association in stakeholder meetings, sent written communications to hospital administrations, received IRB approval for oversight of the regional data registry, and worked with local and international experts to develop a regional hypothermia protocol.
Recognizing the varying needs of the hospitals in the region, the process allowed for entry into or self-initiated withdrawal from the program at any time after its initiation. This allowed facilities to develop the internal protocols, educational programs and inter-departmental agreements necessary to ensure high-quality patient care with respect to hypothermia.
Today, we have 60 approved 9-1-1-receiving hospitals within the five boroughs. These include 19 Cardiac Arrest Centers/PCI facilities, 19 Cardiac Arrest Centers, four PCI facilities and 18 hospitals that are neither Cardiac Arrest Centers nor PCI facilities.
Successes & Challenges
Although we’re still in the midst of a formal analysis of the data from the first six months of this program, a number of items highlight the project’s early successes:
As with any new program, we also face challenges; one of the most significant results from our state’s public reporting structure, which documents mortality statistics of individual cardiologists. Performing even a few additional procedures for patients who have a high baseline mortality rate (e.g., post-arrest patients, even with demonstrated ST-segment elevation) can give the false appearance of a high mortality rate for a particular physician or institution. As a result, we continue to push for the adoption of exemptions in the reporting.
At present, adult patients who achieve ROSC after non-traumatic cardiac arrests qualify for transport to a Cardiac Arrest Center. As we move toward the next phase of this project and initiate hypothermia during prehospital resuscitations, we will face a number of additional challenges: We will need to address the question of obligated transport of all arrests, irrespective of ROSC. We will work with hospitals to address the issue of discontinuing hypothermia despite survival to admission for select patients. And to that end, as our registry begins to identify patients who are universally excluded from hypothermia treatment in this present phase (DNR, dementia, severe comorbidities), we may need to develop more selective treatment criteria so as not to initiate hypothermia that Cardiac Arrest Centers would not continue.
Finally, studies in other systems have suggested a volume-outcome relationship among facilities that care for a large number of post-resuscitation cases.(6) Put simply, facilities that receive and manage large numbers of post-arrest patients have better outcomes among those patients. So in the future, we may need to reassess our attempt to be inclusive of all hospitals interested in participating and ensure that hospitals meet a minimum case volume to participate.
Our experience demonstrates that efforts to regionalize cardiac arrest care, even in a large system, can be successfully led from within the EMS community. Regions considering such an approach to cardiac arrest management should consider our lessons learned:
Disclosure: The author has reported receiving honoraria and/or research support, either directly or indirectly, from the sponsor of this supplement. FDNY receives grant funding from Philips Healthcare for other research for which Dr. Freese is also the principal investigator.