Rationale and Strategies for Development of an Optimal Bundle of Management for Cardiac Arrest

Abstract

Objectives: To construct a highly detailed yet practical, attainable roadmap for enhancing the likelihood of neurologically intact survival following sudden cardiac arrest.

Design setting and patients: Population-based outcomes following out-of-hospital cardiac arrest were collated for 10 U.S. counties in Alaska, California, Florida, Ohio, Minnesota, Utah, and Washington. The 10 identified emergency medical services systems were those that had recently reported significant improvements in neurologically intact survival after introducing a more comprehensive approach involving citizens, hospitals, and evolving strategies for incorporating technology-based, highly choreographed care and training. Detailed inventories of in-common elements were collated from the ten 9-1-1 agencies and assimilated. For reference, combined averaged outcomes for out-of-hospital cardiac arrest occurring January 1, 2017, to February 28, 2018, were compared with concurrent U.S. outcomes reported by the well-established Cardiac Arrest Registry to Enhance Survival.

Interventions: Most commonly, interventions and components from the ten 9-1-1 systems consistently included extensive public cardiopulmonary resuscitation training, 9-1-1 system-connected smart phone applications, expedited dispatcher procedures, cardiopulmonary resuscitation quality monitoring, mechanical cardiopulmonary resuscitation, devices for enhancing negative intrathoracic pressure regulation, extracorporeal membrane oxygenation protocols, body temperature management procedures, rapid cardiac angiography, and intensive involvement of medical directors, operational and quality assurance officers, and training staff.

Measurements and main results: Compared with Cardiac Arrest Registry to Enhance Survival (n = 78,704), the cohorts from the 10 emergency medical services agencies examined (n = 2,911) demonstrated significantly increased likelihoods of return of spontaneous circulation (mean 37.4% vs 31.5%; p < 0.001) and neurologically favorable hospital discharge, particularly after witnessed collapses involving bystander cardiopulmonary resuscitation and shockable cardiac rhythms (mean 10.7% vs 8.4%; p < 0.001; and 41.6% vs 29.2%; p < 0.001, respectively).

Conclusions: The likelihood of neurologically favorable survival following out-of-hospital cardiac arrest can improve substantially in communities that conscientiously and meticulously introduce a well-sequenced, highly choreographed, system-wide portfolio of both traditional and nonconventional approaches to training, technologies, and physiologic management. The commonalities found in the analyzed systems create a compelling case that other communities can also improve out-of-hospital cardiac arrest outcomes significantly by conscientiously exploring and adopting similar bundles of system organization and care.

Keywords: bundle of care; cardiac arrest; cardiopulmonary resuscitation; emergency medical services; resuscitation centers; sudden cardiac death survival.

Figure 1.

The bundle of care. No single intervention is effective in the treatment of cardiac arrest. Key interventions that are similar across all 10 emergency medical services systems are in bold. ACD = active compression decompression, AED = automated external defibrillator, CCL = cardiac catheterization laboratory, CPR = cardiopulmonary resuscitation, ECLS = extracorporeal life support program, ECMO = extracorporeal membrane oxygenation, EP = electrophysiologic programs, ETCo₂ = end-tidal Co₂, IO = intraosseous infusion, ITD = impedance threshold device, PCI = percutaneous coronary intervention, SGA = supraglottic airway, TTM = therapeutic temperature management.

Figure 2.

Seven pillars of care. All 10 emergency medical services systems first focused on the rapid delivery of chest compressions and performance of high-quality manual cardiopulmonary resuscitation (CPR) by first responders. Several included the use of one or more CPR feedback tools or guides. All of these systems implemented one or more of the recent technology and procedural advances such as expedited dispatch-assisted CPR instructions or smart phone apps, mechanical CPR, active compression decompression CPR, impedance threshold device airway attachments, elevation of the head and thorax during CPR, targeted temperature management strategies, extracorporeal membrane oxygenation CPR, and rapid percutaneous coronary intervention as part of the bundle. ETCo₂ = end-tidal Co₂, IHCA = in-hospital cardiac arrest, OHCA = out-of-hospital cardiac arrest, ROSC = return of spontaneous circulation, SCA = sudden cardiac arrest.

Figure 3.

Optimal bundle of care. ^⨹Not currently part of the standard American Heart Association or the International Liaison Committee on Resuscitation. Each intervention requires adequate personnel and, in some cases, special devices and technology. Interventions that may be performed by either basic life support or advanced life support (ALS) personnel are found in bullet points that span both groups of rescuers. ACD = active compression decompression, AED = automated external defibrillator, ASAP = as soon as possible, CPR = cardiopulmonary resuscitation, ECMO = extracorporeal membrane oxygenation, ETCo₂ = end-tidal carbon dioxide, HUP = head up CPR, IO = intraosseous infusion, IV = IV access, ITD = impedance threshold device, LMA = laryngeal mask airway, Max = maximum, PEA = pulseless electrical activity, PRN = pro re nata, ROSC = return of spontaneous circulation, rSO₂ = regional oxygen saturation from cerebral oximetry, VF, V-Fib = ventricular fibrillation, V-Tach = ventricular tachycardia.

Figure 4.

In-hospital cardiac arrest care. ECG = electrocardiogram, EEG = electroencephalography, GCS = Glasgow Coma Scale, IO = intraosseous infusion, IV = IV access, LV = left ventricular, NSE = neuron specific enolase, PCI = percutaneous coronary intervention, ROSC = return of spontaneous circulation, SBP = systolic blood pressure, SpO₂ = oxygen saturation from pulse oximetry, SSEPs = somatosensory evoked potentials, STEMI = ST-segment elevation myocardial infarction, TTM = therapeutic temperature management, VF, V-Fib = ventricular fibrillation, V-Tach = ventricular tachycardia.