The emergency cardiac arrest response team (eCART): A novel

a Section of Emergency Medicine, Department of Medicine, Baylor College of Medicine, Houston, ... Acute care teams for the treatment of time-sensitive complex.
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Resuscitation journal homepage: www.elsevier.com/locate/resuscitation

Clinical paper

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The emergency cardiac arrest response team (eCART): A novel strategy for improving therapeutic hypothermia utilization following out-of-hospital cardiac arrest夽

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Nathan S. Deal a,∗ , Willard W. Sharp a , Gerasim Orbelyan a , Meredith Borak b , Janet Friant c , Atman Shah c , David G. Beiser a a

Section of Emergency Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, United States Center for Quality, University of Chicago, Chicago, IL 60637, United States c Section of Cardiology, University of Chicago, Chicago, IL 60637, United States b

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Article history: Received 27 June 2014 Received in revised form 21 September 2014 Accepted 6 October 2014

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Keywords: Cardiac arrest Therapeutic hypothermia Cardiopulmonary resuscitation (CPR)

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1. Introduction

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Background: Out-of hospital cardiac arrest (OHCA) is associated with significant mortality. Therapeutic hypothermia is one of the few interventions that have been shown to increase post-arrest survival as well as enhance neurologic recovery. Despite clinical guidelines recommending the use of therapeutic hypothermia (TH) following cardiac arrest, utilization rates by physicians remain low. We hypothesized that the development of a multi-disciplinary emergency cardiac arrest response team (eCART) would enhance therapeutic hypothermia utilization in the emergency department for OHCA. Methods and results: An eCART (emergency department cardiac arrest response team) was created at a single site academic urban emergency department. The eCART team consisted of a physician hypothermia consultant, a cardiologist, a clinical pharmacist, a respiratory therapist and a chaplain. These providers were notified by page prior to the arrival of an OHCA patient and responded to the ED in person or by phone to support the resuscitation. Analysis of pre- and post-intervention data demonstrated a significant increase in the rate of TH utilization (64% to 96%). There was a non-significant decrease in the time to target temperature. Conclusions: The creation of a coordinated, multi-disciplinary care team, providing real-time support for OHCA patients increased TH utilization in an emergency department. © 2014 Published by Elsevier Ireland Ltd.

Sudden cardiac arrest is a leading cause of death in the United States, estimated to affect over 630,000 people each year.1 Mortality for out-of-hospital cardiac arrest (OHCA) remains high with roughly 6.4% surviving to hospital discharge and a significant number of these survivors experiencing neurologic deficits as a result.2 Therapeutic hypothermia (TH) remains one of the few therapies available for patients who achieve return of spontaneous circulation (ROSC) with demonstrated benefits in survival to discharge as well as neurologic outcomes.3,4 Despite clinical guidelines recommending the incorporation of TH for the treatment of OHCA

夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.10.006. ∗ Corresponding author. E-mail address: [email protected] (N.S. Deal).

comatose patients with ROSC,5 utilization of TH remains low among providers.6,7 Important barriers to TH utilization include unfamiliarity with hypothermia protocols and the lack of a standardized approach. Acute care teams for the treatment of time-sensitive complex diseases such as trauma,8 acute ST-segment Elevation Myocardial Infarction (STEMI),9 and acute stroke10 have been developed to overcome these barriers and have been demonstrated to improve survival and decrease mortality. Acute care teams facilitate rapid clinical decision-making, standardize care, and reduce the time to life-saving interventions. To date, only limited development of acute care teams for OHCA have been described and data supporting their potential to improve care remains limited.11,12 We hypothesized that the creation of an emergency department cardiac arrest response team (eCART) would improve utilization of therapeutic hypothermia by overcoming identified barriers to its use and improve outcomes for OHCA patients.

http://dx.doi.org/10.1016/j.resuscitation.2014.10.006 0300-9572/© 2014 Published by Elsevier Ireland Ltd.

Please cite this article in press as: Deal NS, et al. The emergency cardiac arrest response team (eCART): A novel strategy for improving therapeutic hypothermia utilization following out-of-hospital cardiac arrest. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.10.006

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2. Methods This study was a retrospective pre- and post-intervention analysis of all consecutive OHCA patients that presented to a single urban, academic, tertiary emergency department between January 1st, 2010 and December 31st, 2012. The institutional review board at the University of Chicago Medical Center (Chicago, IL) approved of the study protocol. An emergency department cardiac arrest response team (eCART) was created to provide a tiered, rapid, response to patients presenting to the emergency department for OHCA. The eCART response was triggered manually by emergency department providers, who upon radio notification by EMS agencies of an OHCA patient en route to the facility, would activate the eCART team through an operator-facilitated group paging system. Following activation, the initial response team comprised of a clinical pharmacist, a respiratory therapist and a chaplain, would respond immediately to the emergency department resuscitation bay. These care providers would support the primary team in the emergency department with dosing of peri-arrest medications, ventilatory support and family counseling. After a delay of 10 min, designed to allow for patient arrival and transfer of care from EMS to ED providers, the on-call cardiology fellow would either arrive at bedside or call the attending ED physician to discuss the need for emergent percutaneous transluminal coronary catheterization (PTCA) or invasive hemodynamic support. After 15 min, an oncall hypothermia consulting physician would respond by phone to determine patient eligibility for TH and provide just-in-time instruction to the treating team on the induction and maintenance of TH. Patients were deemed eligible for TH if they achieved return of spontaneous circulation (ROSC) with persistent coma, defined as inability to open eyes to pain and inability to follow commands, regardless of initial rhythm (asystole, PEA, VT, VF). Patients were excluded from TH if they were less than 18 years of age, pregnant, SBP < 90 mmHg despite fluids and vasopressors, refractory ventricular arrhythmias (VF, VT), other more likely causes of coma, asymmetry in neurologic exam, significant pre-existing neurologic impairment, uncontrollable bleeding or terminal illness. Therapeutic hypothermia was initiated as soon as possible following initial eligibility screening. Cooling protocols allowed for the use of either an intravenous cooling catheter or surface cooling apparatus. Cooling induction was generally aided by the application of ice packs to the neck, axilla and groin and infusion of chilled

saline intravenously or per gastric lavage. Patients were cooled as quickly as possible to a target temperature between 32◦ C and 34◦ C. Hypothermia was maintained for 24 h before rewarming at a rate of roughly 0.5◦ C per hour. Following rewarming to 36.5◦ C, temperature control devices were continued to prevent rebound hyperthermia. For analysis, OHCA patients were identified by a retrospective chart review of the electronic medical record (EMR). Multiple EMR search modalities were used to capture all eligible patient encounters including a search of cardiac arrest related diagnostic codes and chief complaint key word searches. Also, all cases triaged with an emergency severity index (ESI) level 1 and emergency department deaths, and pharmacy code sheets were reviewed for the study time period. Post hoc determination of eligibility for TH was determined by physician evaluators using the previously mentioned criteria. Induction success was defined as the ability of a TH-eligible patient to have a single documented core temperature between 32 and 34 degrees Celsius, measured by either indwelling bladder or esophageal temperature probe. Twenty one months of data were collected in the pre-intervention phase and 15 months in the post-intervention phase. Continuous variables, such as time-to-target temperature, were reported by means with inter-quartile ranges, compared using unpaired t-test, and expressed in p-values. Differences between observed outcome rates of ROSC, survival to discharge and cardiac catheterization were compared with Chi-squared analysis and expressed in p-values.

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3.1. Characteristics of the patients

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A total of 191 consecutive OHCA patients presented to the emergency department in the 3 years of the study. The preinterventional cohort included 86 patients with 105 patients in the post-interventional cohort. The cohorts demonstrated similar characteristics in age, gender, and initial rhythm as shown in Table 1. 3.2. Therapeutic hypothermia utilization and time to target temperature

Pre-intervention

Post-intervention 15 Months 22 Sept 2011–31 Dec 2012 (N = 105)

Age (yrs) Median IQR

63 20.5

64.5 22.5

Male sex (%) Witnessed arrest (%)

54 (63%) 47 (55%)

57 (54%) 70 (67%)

0.24 0.10

Initial Rhythm (%) Asystole PEA VF/VT Unknown

36 (42%) 29 (34%) 19 (22%) 2 (2%)

35 (33%) 48 (46%) 21 (20%) 1 (1%)

0.23 0.10 0.73 0.59

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Hypothermia induction success was significantly higher following the intervention. In the post-intervention group, 23 of 24 (96%) eligible patients successfully achieved goal temperature (32–34◦ C).

21 Months 1 Jan 2010–21 Sept 2011 (N = 86)

p-Value

Table 2 Therapeutic hypothermia induction success.

TH eligible TH performed (%) Avg time to target (min)

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3. Results

Table 1 Clinical characteristics of the 191 consecutive OHCA patients. Characteristic

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Pre-intervention (N = 86)

Post-intervention (N = 105)

p-Value

14 9 (64%) 289

24 23 (96%) 216

0.01 0.2

Please cite this article in press as: Deal NS, et al. The emergency cardiac arrest response team (eCART): A novel strategy for improving therapeutic hypothermia utilization following out-of-hospital cardiac arrest. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.10.006

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Table 3 ROSC and survival to discharge.

ROSC > 20 min (%) Survival to discharge (%)

Pre-intervention (N = 86)

Post-intervention (N = 105)

p-Value

22 (26%) 4/22 (18%)

33 (31%) 8/33 (24%)

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Table 4 Emergent cardiac catheterization rates.

Emergent Cath (%)

Pre-intervention (N = 22)

Post-intervention (N = 32)

p-Value

10 (45%)

14 (44%)

0.90

By comparison, only 9 of 14 (64%) eligible patients were successfully cooled (p-value is 0.01). Time to target temperature, defined 136 from time of ROSC to first documentation of a temperature less than 137 or equal to 34◦ C, demonstrated a trend to improved times in the 138 post- (216, IQR = 203) vs. pre-intervention (289, IQR = 347) group 139 Q2 (p = 0.2) (Tables 2–4). 134 135

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3.3. ROSC and survival

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Rates of ROSC and survival to discharge data were collected for patients in both cohorts. In the pre-intervention cohort, 26% of patients presenting with OHCA achieved ROSC for at least 20 min with 18% surviving to discharge. In the post-intervention group, 31% of patients achieved ROSC with a survival rate of 24%.

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3.4. Catheterization lab utilization

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Rates of emergent cardiac catheterization were also tracked for those patients achieving ROSC in both cohorts. Of the 55 patients who achieved ROSC, catheterization data was available for 54 patients. No significant difference was noted in the rates of emergent catheterization of the pre- and post-interventional cohorts; 44% vs. 45%, respectively.

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4. Discussion

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Specialized teams to provide acute critical care in the emergency department have been developed for time sensitive diseases as trauma, stroke, and STEMI in order to overcome systemic barriers that delay rapid deployment of necessary medical therapies. The rapid treatment of OHCA with TH is also a time sensitive process, which has identified barriers to its utilization. To overcome these barriers, we describe for the first time, the development of a specialized response team for OHCA we termed eCART (emergency department cardiac arrest response team). As expected, development of an eCART team was associated with a significant increase in the number of eligible patients receiving TH and reduced the time to target temperature. Multiple barriers to the use of therapeutic hypothermia have been reported previously, including lack of provider knowledge of protocols, inclusion criteria, and cooling equipment may have limited the use of this modality in the past.13,14 Providing care teams with prompt access to hypothermia experts who can address these concerns in real-time, allows for a greater number of patients to have access to these life-saving treatments. Previous work15,16 has attempted to address these barriers by providing order sets, supply kits, targeted educational sessions, on-call physicians trained in TH, etc., in an effort to improve utilization. Our work builds on this by describing for the first time, a multi-disciplinary real-time response, paired with pre-hospital activation, to provide these patients with the resources needed. Our study was not designed to differentiate which elements of our eCART were responsible for the improved outcomes.

A central concern in the creation of this multi-disciplinary response is implementation cost. The academic system upon which this eCART response was built has a clinical pharmacist, respiratory therapist, and chaplain in-house and an interventional cardiology on-call, requiring no additional resource outlay to implement. The ability to involve the pharmacists in peri-arrest resuscitation and the chaplains in family counseling represented further training opportunities for these care providers. Our study was performed at a tertiary academic center with salaried physicians who were willing to provide additional on-call coverage without additional compensation. Despite this uncompensated on-call coverage and the reallocation of pharmacy, chaplaincy and RT resources to the care of these cardiac arrest patients, these services welcomed the opportunity to participate in the eCART because of the educational benefits and the positive impact on patient care. In systems without these resources already in place, the implementation of this model of care may represent additional financial cost. Therapeutic hypothermia utilization rates improved significantly during the study, ultimately achieving a 96% utilization rate with an average decrease in the time to target temperature of 73 min. Analysis of human17 and animal18 data has suggested that delays in therapeutic hypothermia have limited or abolished the potential benefits of this therapy. The eCART response successfully limited these delays in therapy. Rates of ROSC and survival to discharge were also tracked in this study. Although there was a trend toward improvement in both of these metrics, the results were not statistically significant. However, previous work has demonstrated the survival advantage and neurological advantage to this therapy, and it may be that the number of patients included in this study was insufficient to demonstrate a statistically significant difference in these metrics. Rates of cardiac catheterization were tracked without any significant difference in the pre- and post-interventional cohorts. Previously published literature has demonstrated the correlation between significant coronary artery disease and cardiac arrest,19,20 as well as the survival advantage associated with emergent PCI following cardiac arrest.21 We expected that the addition of cardiologist to the eCART would result in improvements in these catheterization rates, although this effect was not observed. There are inherent challenges to the interpretation of a preand post-interventional study. Ongoing education regarding therapeutic hypothermia and growing provider comfort with the intervention continued to occur during the post-intervention timeframe which may have improved the rates of utilization as well as the time to target temperature. Future work will include the development of eCART teams at other healthcare institutions in an attempt to reproduce the success demonstrated here. Pooling of data from multiple care sites may be able to demonstrate survival advantages that require greater numbers to elucidate. Additional collaboration with cardiology colleagues can investigate techniques to increase emergent catheterization rates in the potential effect on survival following cardiac arrest.

Please cite this article in press as: Deal NS, et al. The emergency cardiac arrest response team (eCART): A novel strategy for improving therapeutic hypothermia utilization following out-of-hospital cardiac arrest. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.10.006

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5. Conclusion This study provides strong support for the development of a coordinated care team for improved utilization of therapeutic hypothermia in post-cardiac arrest care. The gains demonstrated at this site mimic similar improvements in care that have been seen in other time-sensitive, critical diseases such as STEMI and stroke that have utilized coordinated systems of care to provide the best care. Conflict of interest statement None. Acknowledgements This work was supported in part by the following grants: NIH K08-HL103901-02 (Sharp), NIH K08-HL091184 (Beiser). References 1. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation 2012;125:e2–220, http://dx.doi.org/10.1161/CIR.0b013e31823ac046. 2. Nichol G, et al. Cumulative meta-analysis of the effectiveness of defibrillatorcapable emergency medical services for victims of out-of-hospital. Ann Emerg Med 1999. 3. Bernard S, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. NEJM 2002;346:557–63. 4. England TN. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. NEJM 2002;346:549–56. 5. Nolan JP, Morley PT, Vanden Hoek TL, et al. ILCOR Advisory Statement. Therapeutic Hypothermia After Cardiac Arrest. An Advisory Statement by the Advanced Life Support Task Force of the. International Liaison Committee on Resuscitation. Members of the Advanced Life Support Task Force; 2003, http://dx.doi.org/10.1161/01.CIR.0000079019.02601.90. 6. Merchant RM, Soar J, Skrifvars MB, et al. Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest. Crit Care Med 2006;34:1935–40, http://dx.doi.org/10.1097/01.CCM.0000220494.90290. 92. 7. Patel PV, et al. Therapeutic hypothermia after cardiac arrest is underutilized in the United States. Ther Hypothermia Temp Manage 2011;1:199–203, http://dx.doi.org/10.1089/ther.2011.0015.

8. Barbosa RR, et al. Increasing time to operation is associated with decreased survival in patients with a positive FAST examination requiring emergent laparotomy. J Trauma Acute Care Surg 2013;75:S48–52, http://dx.doi.org/10.1097/TA.0b013e31828fa54e. 9. Cannon CP, et al. Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patient undergoing angioplasty for acute myocardial infarction. JAMA 2000;283:2941–7, http://dx.doi.org/10.1001/jama.283.22.2941. 10. Adams HP, et al. Guidelines for the early management of with ischemic adults stroke. Circulation 2007;115:e478–534, http://dx.doi.org/10.1161/CIRCULATIONAHA.107.181486. 11. Gaieski DF, et al. Early goal-directed hemodynamic optimization combined with therapeutic hypothermia in comatose survivors out-of-hospital cardiac arrest. Resuscitation 2009;80:418–24, of http://dx.doi.org/10.1016/j.resuscitation.2008.12.015. 12. Donnino MW, et al. The development and implementaof cardiac tion arrest centers. Resuscitation 2011;82:974–8, http://dx.doi.org/10.1016/j.resuscitation.2011.03.021. 13. Merchant RM, et al. Therapeutic hypothermia utilization among physicians after resuscitation after cardiac arrest. Crit Care Med 2006;34:1935–40, http://dx.doi.org/10.1097/01.CCM.0000220494.90290.92. 14. Brooks SC, Morrison LJ. Implementation of therapeutic hypothermia guidelines for post-cardiac arrest syndrome at a glacial pace: seeking guidance from the knowledge translation literature. Resuscitation 2008;77:286–92, http://dx.doi.org/10.1016/j.resuscitation.2008.01.017. 15. Rittenberger JC, et al. Outcomes of a hospital-wide plan to improve care of comatose survivors of cardiac arrest. Resuscitation 2008;79:198–204, http://dx.doi.org/10.1016/j.resuscitation.2008.08.014. 16. Sunde K, et al. Implementation of a standardized treatment protocol for post-resuscitation care after out-of-hospital cardiac arrest. Resuscitation 2007;73:29–39, http://dx.doi.org/10.1016/j.resuscitation.2006.08.016. 17. Sendelbach S, et al. Effects of variation in temperature management on cerebral performance category scores in patients who received therapeutic hypothermia post cardiac arrest. Resuscitation 2012;83:829–34, http://dx.doi.org/10.1016/j.resusctiation.2011.12.026. 18. Che D, et al. Impact of therapeutic hypothermia onset and duration on survival, neurologic function, and neuro-degeneration after cardiac arrest. Crit Care Med 2011;39:1423–30, http://dx.doi.org/10.1097/CCM.0b013e318212020a. 19. Spaulding CM, et al. Immediate coronary angiography in survivors of out-of-hospital cardiac arrest. NEJM 1997;336:1629–33, http://dx.doi.org/10.1056/NEJM199706053362302. 20. Chelly J, et al. Benefits of an early and systematic imaging procedure after cardiac arrest: insights from the PROCAT registry. Resuscitation 2012;83:1444–50, http://dx.doi.org/10.1016/j.resuscitation.2012.08.321. 21. Dumas F, et al. Long-term prognosis following resuscitation from out of hospital cardiac arrest: role of percutaneous coronary intervention and therapeutic hypothermia. J Am Coll Cardiol 2012;60:21–7, http://dx.doi.org/10.1016/j.jacc.2012.03.036.

Please cite this article in press as: Deal NS, et al. The emergency cardiac arrest response team (eCART): A novel strategy for improving therapeutic hypothermia utilization following out-of-hospital cardiac arrest. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.10.006

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