Dallas 2015 TFQO: Judith Finn EVREVs: Judith Finn #227 / Dion Stub #COI Taskforce: EIT Cardiac Arrest Centres

Dallas 2015 COI Disclosure (specific to this systematic review) Commercial/industry JF - #227 Partial salary support from St John Ambulance Western Australia Potential intellectual conflicts DS - # is the lead author on one of the studies included in the review

Dallas CoSTR (1) Seven observational studies showed wide variability in survival to hospital discharge, 1-month survival, or length of intensive care unit (ICU) stay among hospitals caring for patients after resuscitation from cardiac arrest. One North American observational study showed that higher- volume centers (>50 ICU admissions following cardiac arrest per year) had a better survival to hospital discharge than low-volume centers (<20 cases admitted to ICU following cardiac arrest) for patients treated for either in- or out-of-hospital cardiac arrest. Another observational study showed that unadjusted survival to discharge was greater in hospitals that received ≥40 cardiac arrest patients/year compared with those that received <40 per year, but this difference disappeared after adjustment for patient factors. Three LOE 3 observational studies with historic control groups showed improved survival after implementation of a comprehensive package of post resuscitation care that included therapeutic hypothermia and percutaneous coronary intervention (PCI). Two small LOE 3 observational studies demonstrated a trend toward improvement that was not statistically significant when comparing historic controls with the introduction of a comprehensive package of post resuscitation care, which included therapeutic hypothermia, PCI, and goal-directed therapy. One LOE 4 observational study suggested improved survival to discharge after out of hospital cardiac arrest in large hospitals with cardiac catheter facilities compared with smaller hospitals with no cardiac catheter facilities. Another LOE 4 observational study also showed improved outcome in hospitals with cardiac catheter facilities that was not statistically significant after adjustment for other variables. Three LOE 3 studies of out-of-hospital adult cardiac arrest with short transport intervals (3 to 11 minutes) failed to demonstrate any effect of transport interval from the scene to the receiving hospital on survival to hospital discharge if ROSC was achieved at the scene.

Dallas CoSTR (2) Although there is no direct evidence that regional cardiac resuscitation systems of care (SOCs) improve outcomes compared with no SOC, extrapolation from multiple studies (LOE 5 for this question) evaluating SOC for other acute time-sensitive conditions suggested a potential benefit. High-quality randomized trials and prospective observational studies of ST elevation myocardial infarction (STEMI) SOCs demonstrated improved or neutral outcomes compared with no SOC. Many case-control studies of regionalized care for trauma patients demonstrated improved or neutral outcomes when comparing an SOC with no SOC. One study that evaluated a trauma SOC showed a higher mortality in the trauma center. Observational studies and randomized trials showed that organized care improves outcomes after acute stroke. Treatment Recommendation While extrapolation from randomized and observational studies of SOCs for other acute time-sensitive conditions (trauma, STEMI, stroke) suggests that specialist cardiac arrest centers and systems of care may be effective, there is insufficient direct evidence to recommend for or against their use.

Dallas 2015 C2015 PICO Population: Adults and children in out-of- hospital cardiac arrest (OHCA) Intervention:transport to a specialist cardiac arrest centre Comparison: no directed transport Outcomes: 8-Criticalneurologically intact survival at 30 days 7-Criticalsurvival to hospital discharge with good neurological outcome 6-Importantsurvival to hospital discharge 5-Importanthospital admission 3-LowROSC

Dallas 2015 Inclusion/Exclusion & Articles Found List Inclusions/Exclusions Included all comparative studies (prospective and retrospective) and case studies examining the transporting/treatment of OHCA patients to/at cardiac arrest centres. Excluded studies that did not directly address the PICO question, abstract-only studies, unpublished studies, letters, editorials and reviews. Insert Number of Articles Finally Evaluated 23 observational studies

Dallas Proposed Treatment Recommendations We recommend patients should be considered for transfer to specialist cardiac arrest centers as part of wider system of care for management of patients with out of hospital cardiac arrest. (weak recommendation, very low quality of evidence). Values and preferences statement: In making this recommendation we recognize the development of cardiac arrest centers may be considered as a health improvement initiative, as has been performed for other critical conditions including myocardial infarction, stroke, and major trauma, without the evidence of randomized trials.

Dallas 2015 Risk of Bias in studies

Dallas 2015 Key data from key studies (1) Kajino 2010, 549 P: adults with OHCA of presumed cardiac etiology, treated by EMS, and transported I:Critical Care Medical Centre (CCMC) C: Non-critical care hospital (NCCH) O:STHD with good neuro (CPC ≤ 2) CCMC vs NCCH 193/2881 (6.7%) vs 213/7502 (2.8%), OR, 2.47; 95% CI, 2.02–3.01; P < 0.001

Dallas 2015 Key data from key studies (2) Tagami 2012, 589 P: OHCA where resus attempted; >15 years old; non-traumatic I:post-implementation of post resuscitation system of care C: pre-implementation of post resuscitation system of care O: One-month survival CPC 1-2: 0.5% (4/770) before vs 3% (21/712) after. OR, 5.8; 95% CI, 2.0 –17.0; p<0.001; adjusted OR, 7.8; 95% CI, 1.6 –39.0; P=0.01

Dallas 2015 Evidence profile table(s)

Dallas 2015 Evidence profile table(s)

Dallas 2015 Proposed Consensus on Science statements Outcome: Neurological Intact Survival For the critical outcome of “neurologically intact survival” we have identified very low quality evidence from 9 observational studies, enrolling over 19,000 patients. Two studies examined neurological intact survival at 30 days, and seven studies reported survival to hospital discharge with good neurological outcome. Studies were downgraded for significant risk of bias and indirectness in answering study question. There was an association between improved neurological intact survival and patient transport to specialist cardiac arrest centers.

Dallas 2015 Proposed Consensus on Science statements Outcome: Survival For the important outcome of “survival” we have identified very low quality evidence from 18 studies with over 120,000 patients. Two studies examined survival at 30 days, 16 studies reported survival to hospital discharge, and one study reported survival at 4.6 years. Studies were downgraded for significant risk of bias and indirectness in answering study question, with heterogeneity in reported hospital factors associated with differences in patient survival. There was an association with survival and transport to a cardiac arrest centre, however, which hospitals factors are most related to patient outcome provided inconsistent results.

Dallas 2015 Draft Treatment Recommendations We recommend patients should be considered for transfer to specialist cardiac arrest centers as part of wider system of care for management of patients with out of hospital cardiac arrest. (weak recommendation, very low quality of evidence). Values and preferences statement: In making this recommendation we recognize the development of cardiac arrest centers may be considered as a health improvement initiative, as has been performed for other critical conditions including myocardial infarction, stroke, and major trauma, without the evidence of randomized trials.

Dallas 2015 Knowledge Gaps Other specific worksheets that would be helpful The relationship between actual post- resuscitation care received (at cardiac arrest centres compared to non-cardiac arrest centres) and patient survival outcomes.

Dallas 2015 Knowledge Gaps (eg. ETT vs BVM) Specific research required (from 2010) Safe journey time or distance for patient transport under various conditions Essential treatments that a cardiac resuscitation center should offer Role of secondary transport from receiving hospital to a regional center Ethics of conducting an RCT of standard care versus transport to a cardiac resuscitation center

Dallas 2015 Next Steps This slide will be completed during Task Force Discussion (not EvRev) and should include: Consideration of interim statement Person responsible Due date Essential slide (one slide only). Estimated time <30 sec