What if every patient who suffered an out-of-hospital cardiac arrest could have access to the same kind of specialized care found in a trauma center? Arizona is answering that question by becoming the first state to create a network of cardiac arrest centers, which draw on the concept of trauma centers to deliver standardized care to patients.
"There are things we can do to improve outcomes in [these] patients, but hospitals aren't doing them routinely," says Bentley Bobrow, MD, Mayo Clinic, Scottsdale, Ariz. and medical director for the Bureau of Emergency Medical Services & Trauma System, Arizona Department of Health Services. "In a perfect world, I'd like every hospital to be able to deliver every state-of-the-art therapy, but staffing and finances make that impossible." That's where cardiac arrest centers come in.
It Just Takes Four
The Arizona Department of Health Services' Save Hearts in Arizona Registry & Education program manages the Cardiac Arrest Center Consortium and provides resources for aspiring and existing cardiac arrest centers (See Implementation strategy for Cardiac Arrest Center).
It only takes four components to be a cardiac arrest center: therapeutic hypothermia, an ability to provide 24/7 interventional therapy for cardiac revascularization, completion of a one-page data tool and submission of the data tool to the Cardiac Arrest Center Consortium. Hospitals receive reports of their data, as well as aggregate data for the state.
Therapeutic Hypothermia Now
Therapeutic hypothermia is the cornerstone of the cardiac arrest center. The American Heart Association endorsed therapeutic hypothermia in 2003 on the basis of positive results from two large clinical trials, yet adoption of this life-saving treatment has lagged behind. A survey of 52 ED medical directors in Arizona found that only five (10%) of EDs routinely used the procedure, and only two of those had structured protocols.
Common reasons for not using therapeutic hypothermia include equipment cost, lack of knowledge of the evidence supporting its use, and lack of trained personnel. Bobrow says, "[The clinicians are] afraid of doing it the wrong way. It's a complicated strategy."
More research is needed on the intricacies of the procedure, such as what type works best, but Bobrow says clinicians need to embrace the therapy. Several hospitals in Arizona have cooled multiple patients and found improved outcomes. "We don't know what's the best way, but we know that it improves outcomes," Bobrow notes.
Paramedics in Arizona are starting to think of the procedure as an option for patients who are successfully resuscitated but still in a coma. Some fire department protocols call for starting cool saline during transport to the hospital. When the patient hits the ED doors, staff and physicians are ready to go, says Kristen Slee, RN, MSN, CEN, unit-based educator and community outreach coordinator for the Mayo Clinic ED.
Once the ED physician decides the patient is a candidate for therapeutic hypotherapy, it's time to set up the Arctic Sun machine, which uses thermal-heat exchange cooling pads to control temperature. "It's not hard to use," says Slee, "It only takes about 10 or 15 minutes for a couple of people to set it up." The extra help is needed to place the cooling pads: one on each leg, one for the chest and one for the back. A urinary catheter with a temperature probe is inserted for monitoring.
The cooling pads are placed over the ECG and defibrillation pads. Slee says the water is "deep in the pad" so defibrillating the patient is not a danger. Patients can even undergo percutaneous coronary interventions while receiving hypothermia.
Responses From Staff and Family
Slee says those wanting to start the therapy in their ED "need to show the positive data to people to get the buy in." Anxiety is natural because it is still not routine. "When staff see the potential, they're excited to use it," says Slee, "but it makes them a little nervous too." Special resource sheets were developed to help staff.
Sometimes families worry their loved ones will shiver from being cold. Slee tells them that the temperature reduction is mild (32 to 34 degrees C) and that medications such as sedatives and paralytics are given to prevent shivering.
Future of Cardiac Arrest Centers
Arizona has 15 cardiac arrest centers as of July 18 and Bobrow anticipates several more. The goal is that an out-of-hospital cardiac arrest patient anywhere in the state would have ready access (less than 15 minutes of additional transport time) to a cardiac arrest center.
More research is needed, but researchers in Norway found that using a standard postresuscitation protocol, which included therapeutic hypotherapy, PCI and control of hemodynamics, blood glucose, ventilation and seizures improved the rate of survival to hospital discharge with a favorable neurological outcome from 26% to 56%.
Bobrow foresees a time when cardiac arrest centers exist throughout the country. "We're at a point where an aggressive approach at cardiac arrest centers can significantly improve survival," he says.
Strategy for Center Implementation
Meet the four fundamental components:
Therapeutic hypothermia protocol for out-of-hospital cardiac arrest
Around-the-clock cardiac intervention capability including protocol for out-of-hospital cardiac arrest
System for completing the one-page data collection tool
Commitment to contribute data to the Cardiac Arrest Center Consortium.
-Cynthia Saver, RN, MS, Nurse.com