Elsevier

Resuscitation

Volume 81, Issue 5, May 2010, Pages 518-523
Resuscitation

Clinical paper
A geospatial assessment of transport distance and survival to discharge in out of hospital cardiac arrest patients: Implications for resuscitation centers,☆☆

https://doi.org/10.1016/j.resuscitation.2009.12.030Get rights and content

Abstract

Objectives

National leaders have suggested that patients with an out of hospital cardiac arrest (OOHCA) may benefit from transport to specialized hospitals. We sought to assess the survival of OOHCA patients by transport distance and hospital proximity.

Methods

Prospective, cohort study of OOHCA patients in 11 Resuscitation Outcomes Consortium (ROC) sites across North America. Transport distance and hospital proximity was calculated using weighted centroid of census tract location by Geographic Information Systems (GIS). Patients were stratified into quartiles based on transport distance to the receiving hospital calculated via GIS. Descriptive statistics were used to describe characteristics by transport distance and to compare proximity to other hospitals. Multivariate logistic regression was used to evaluate the impact of transport distance on survival.

Results

26,628 patients were identified, 7540 (28%) were transported by EMS and included in the final analysis. The median transport time was 6.3 min (IQR 5.4); the median transport distance being 2.4 miles (3.9 km). Most patients were taken to the closest hospital (71.7%; N = 5412). However, unadjusted survival to discharge was lower for those taken to the closest compared to further hospitals (12.1% vs. 16.5%) despite similar patient characteristics. Transport distance was not associated with survival on logistic analysis (OR 1.00; 95% CI 0.99–1.01).

Conclusions

Survival to discharge was higher in OOHCA patients taken to hospitals located further than the closest hospital while transport distance was not associated with survival. This suggests that longer transport distance/time might not adversely affect outcome. Further studies are needed to inform policy decisions regarding best destination post-cardiac arrest.

Introduction

Out of hospital cardiac arrest (OOHCA) continues to be a leading cause of death in the United States (U.S.).1 Survival from OOHCA varies considerably across the country and until recently had been relatively stagnant over the last several decades.2 However, the advent of recent interventions such as induced-hypothermia and early cardiac catheterization, along with higher quality cardiopulmonary resuscitation (CPR) in the prehospital setting, has led to a distinct increase in survival.3, 4, 5 Despite these advances, various regions and hospitals in the U.S. have been slow to adopt such measures in order to improve outcomes from OOHCA.

Based on this information, as well as the success of regionalized trauma centers and their impact on survival in injured patients,6, 7 many leaders have called for development and implementation of cardiac arrest centers.8 Some areas of the country, such as the state of Arizona, are actively developing such centers.9 However, before such centers are deemed appropriate, it must be determined that it is safe to bypass closer hospitals in order to transport a patient to a hospital further away but with additional resources to optimize the care of such patients. To date, there has been limited data evaluating the safety and impact of such a practice on survival of OOHCA patients.10, 11, 12

In light of the growing interest in developing and implementing regionalization of specialized care for OOHCA, we sought to assess the impact of transport distance on survival in OOHCA patients and to assess the characteristics of hospitals that care for OOHCA patients. We hypothesized that an increase in transport distance would not be associated with a decrease in survival, nor would transport to a closer hospital be associated with improvement in survival.

Section snippets

Methods

This was a secondary analysis of a prospective, observational, multi-center, population-based cohort study in 10 of 11 North American sites participating in the Resuscitation Outcomes Consortium (ROC). One site was excluded due to incomplete case capture across the study's time frame. This project was approved by 74 U.S. Institutional Review Boards (IRBs) and 34 Canadian Research Ethics Boards as well as 26 Emergency Medical Services (EMS) IRBs and the IRB at the Ohio State University Medical

Results

A total of 26,628 patients were identified, of which 7540 (28%) were transported to a hospital with complete data (Fig. 1). Of these, 5412 (72%) were transported to the closest hospital. The majority of patients were male, arrested in a private setting, and had a non-VF/VT presenting rhythm (Table 1). Receiving hospitals located further from the events were more likely to have a cardiac catheterization lab, an electrophysiology lab, higher patient volumes, and were a teaching institution (Table

Discussion

In this project, we have observed that transport distance in patients with an OOHCA is not associated with survival, and that transport to a closer hospital may indeed be associated with lower odds of survival. This is consistent with prior literature that has investigated whether an increase in transport time is associated with a decrease in the odds of survival.10, 11, 12 This data, coupled with the prior literature, suggests that transport to further hospitals, such as cardiac arrest

Limitations

This project is not without its limitations. We did not evaluate for the impact of hospital characteristics or interventions at the hospital or patient level. The objective was to assess the impact of transport distance to determine the safety of transporting to hospitals with perhaps more advanced capabilities. However, we did attempt to incorporate these characteristics using our surrogate marker of hospital bypass. As the hospitals located further from the event tended to have more

Conclusions

In this project, transport distance is not associated with survival to discharge in OOHCA patients. This supports the concept that transporting a patient to a further hospital with more advanced capabilities may be beneficial and safe. Future research should evaluate the impact of hospital-based interventions and policy changes that promote resuscitation centers on survival in OOHCA patients in order to evaluate the potential effectiveness of cardiac arrest receiving centers.

Funding: The ROC is

Conflict of interest statement

None of the authors of this paper have any financial or personal relationships with other people or organizations that could inappropriately influence (bias) this paper.

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  • Cited by (0)

    A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.12.030.

    ☆☆

    Presented in Abstract Form at the Society for Academic Emergency Medicine Annual Research Forum, New Orleans, LA, May 17, 2009.

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