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Resuscitation
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Editorial
Hospital
care
after
resuscitation
from
out-of-hospital
cardiac
arrest:
The
emperor’s
new
clothes?
The
large
regional
variation
in
outcome
after
treatment
for
out-
of-hospital
cardiac
arrest
(OHCA)
led
to
efforts
to
develop
and
implement
cardiac
resuscitation
systems
of
care
that
include
interconnected
community,
emergency
medical
services
(EMS)
and
hospital
efforts
to
measure
and
improve
the
process
and
outcome
of
care
for
this
population.
assumptions
of
these
efforts
are
that
care
provided
for
patients
with
OHCA
is
better
at
some
hos-
pitals
that
receive
such
patients
than
others,
and
that
resuscitated
patients
should
be
preferentially
transported
to
higher-performing
hospitals.
In
this
volume
of
Resuscitation,
two
investigations
describe
whether
the
characteristics
of
receiving
hospitals
are
associated
with
outcome
after
OHCA.
In
a
retrospective
analysis
that
com-
bined
quality
improvement
data
from
the
Cardiac
Arrest
Registry
to
Enhance
Survival
(CARES)
registry
with
administrative
information
about
hospital
characteristics
and
hospitals’
self-report
of
whether
they
use
hypothermia
to
assess
the
relationship,
Cudnik
et
al.
eval-
uated
whether
increasing
hospital
volume
of
OHCA
patients
was
associated
with
improved
survival.
included
adults
who
had
OHCA
of
presumed
cardiac
etiology,
were
treated
by
EMS,
and
were
directly
transported
to
a
hospital.
The
analysis
used
multi-
level
hierarchical
logistic
regression
to
adjust
for
the
interaction
between
patient-level
factors
with
hospital
characteristics
and
the
association
between
hospital
characteristics
within
different
sites.
A
significant
relationship
was
observed
between
trauma
center
designation
but
not
presence
of
a
coronary
catheterization
labora-
tory
or
the
volume
of
patients
received
and
survival
or
neurologic
outcome
among
all
treated
patients
or
those
with
a
first-recorded
shockable
rhythm.
The
hospital
factor
with
the
largest
treatment
effect
in
this
study
was
self-reported
use
of
hypothermia.
Since
only
a
minor-
ity
of
patients
have
hypothermia
induced
at
hospitals
that
report
that
they
use
it,
use
of
hypothermia
may
be
a
surro-
gate
marker
for
other
factors
that
are
associated
with
outcome,
and
attenuate
the
effect
of
hospital
factors
upon
patient
survival
to
discharge.
This
study
restricted
enrollment
to
patients
with
a
cardiac
etiol-
ogy
of
arrest.
There
is
a
twofold
variation
in
the
reported
proportion
of
cardiac
arrests
of
non-cardiac
is
poor
agreement
in
attributing
cause
of
heart
failure
deaths.
from
12-
lead
electrocardiogram
does
not
identify
which
patients
among
those
resuscitated
from
OHCA
have
significant
lesions
at
time
of
emergency
of
the
etiology
of
arrest
is
difficult
to
assess
accurately
in
field.
If
etiology
is
determined
using
hospital
information,
assessing
etiology
is
conditioned
on
survival
to
hospital,
and
analyses
restricted
to
cardiac
etiology
of
arrest
are
susceptible
to
bias.
Thus
the
revised
Utstein
approach
to
comparing
outcomes
after
OHCA
recommended
including
all
treated
patients
rather
than
those
with
a
particular
etiology
or
initial
rhythm.
In
another
retrospective
analysis
published
simultaneously
as
the
CARES
work,
Ro
et
al.
evaluated
the
relationship
between
the
annual
volume
of
patients
received
at
hospitals
and
survival
to
discharge
after
cardiac
arrest
of
non-cardiac
etiology
in
a
national
Korean
registry
derived
from
combination
of
ambulance
run
sheets
with
hospital
data
abstracted
by
trained
additive
modeling
evaluated
for
a
threshold
value
that
discrimi-
nated
between
a
low
and
high
volume
of
patients
received.
Then
multiple
logistic
regression
analysis
evaluated
whether
there
was
an
association
between
the
volume
of
patients
received
and
sur-
vival
to
discharge.
There
was
a
significant
and
important
difference
in
survival
to
discharge
among
patients
transported
to
a
high
vol-
ume
hospital
rather
than
low
volume
hospital
overall
and
within
specific
etiologies
of
arrest.
There
are
several
potential
explanations
why
an
association
between
patient
volume
and
outcome
was
not
observed
in
the
CARES
registry
but
was
in
the
Korean
registry.
The
quality
of
care
may
be
lower
among
CARES
hospitals
than
among
Korean
hospi-
tals,
but
this
seems
unlikely
since
overall
survival
was
greater
in
the
former
than
in
the
latter.
The
accuracy
of
the
data
in
each
reg-
istry
may
differ
as
CARES
performs
limited
data
verification
at
the
source
whereas
staff
of
the
Korean
registry
visit
participating
hos-
pitals
and
review
medical
records
to
identify
information
related
to
covariate
and
outcome.
It
seems
plausible
that
bias
and
confound-
ing
in
CARES
data
may
reduce
the
likelihood
of
identifying
whether
differences
in
care
are
associated
with
differences
in
survival.
Prior
studies
provide
conflicting
evidence
regarding
the
influ-
ence
of
hospital
factors
on
survival
after
OHCA.
A
Japanese
study
that
included
more
10,000
patients
showed
that
OHCA
patients
transported
to
critical
cardiac
care
hospitals
had
improved
1-month
survival
compared
with
patients
transported
to
hospitals
without
specialized
facilities
(6.7%
versus
2.8%,
p
<
0.001,
adjusted
odds
ratio
3.39,
p
<
Swedish
study
of
almost
4000
OHCA
patients
reported
marked
variability
in
hospital
outcomes
after
adjusting
for
pre-hospital
factors,
with
survival
varying
from
14%
to
42%
in
differ-
ent
a
recent
Australian
study
of
2706
patients
who
were
transported
to
hospital
with
return
of
a
spontaneous
cir-
culation
found
that
survival
to
hospital
discharge
was
significantly
greater
in
patients
transported
to
hospitals
with
24
h
interventional
cardiology
facilities,
with
the
best
survival
in
major
trauma-level
hospitals.
US
study
of
109,739
patients
who
received
intensive
0300-9572/$
–
see
front
matter ©
2012 Elsevier Ireland Ltd. All rights reserved.
