Out of Hospital Cardiac Arrest

AIM

To work with BCIS council to develop recommendations to standardise the care of patients suffering a cardiac arrest (of presumed cardiac cause), driving up standards across the UK with the aim of improving survivor outcomes and quality of life.

BACKGROUND INFORMATION

Out-of-hospital cardiac arrest (OHCA) remains a significant problem for the NHS. In England in 2019, ambulance services responded to over 80,000 cardiac arrest calls, of which 31,146 subsequently received treatment.¹ Fewer than a third (30.7%) of patients in whom resuscitation was attempted by ambulance staff were admitted to hospital with a return of spontaneous circulation (ROSC). Overall survival to discharge was 9.6%.¹

In 2017 a national framework for OHCA in England, Resuscitation to Recovery,² set out recommendations across the patient pathway (‘Chain of Survival’) to improve outcomes. One key recommendation was that all patients with ROSC should be taken to a regionally designated cardiac arrest centre (CAC) for further assessment, triage and clinically appropriate treatment. To date, no allocation or formalised network solution for regionalised CAC exists in the UK.

An analysis of 17,604 patients admitted following OHCA to 239 hospitals in England and Wales identified important variations in outcome; mortality by hospital ranged from 10.7% to 66.3% (median 28.6%, IQR 23.2% to 39.1%), with patient and health service factors explaining only 36.1% of this variation.³ The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) review of hospital care of patients admitted after OHCA identified a number of areas for improvement, including prompt access to cardiologists and interventional cardiology services.⁴

The BCIS OHCA focus group was formed in February 2020, but COVID-19 in March 2020 meant that the start of activities and meetings were postponed. The group had the inaugural zoom meeting on 20^th May, where ambitions and work streams were decided. Workstreams will be delivered by BCIS recommendation, abstract and manuscript publication where appropriate.

THE CURRENT PROPOSED WORKSTREAMS

The focus group has identified 2 main themes in cardiac arrest care which if more standardised and networked would lead to better outcomes for cardiac arrest patients and their families.

• Recommendation 1 – to develop a cardiac arrest BCIS decision making support tool for both emergency medical services (EMS) crews and accepting Cardiac arrest centre (CAC) teams. The recommendation will suggest definitions of which subsets of OHCA patients “should” be taken directly to a CAC without discussion, those that definitely “should not be taken to CAC”, and “those that should be discussed with CAC prior to transfer to hospital”. Outcome data and scoring systems must underpin any decision-making support tools, but this will likely help to standardise practice across the UK, minimising geographical, institutional and IC decision making variability.
• Recommendation 2 – Survivor and family follow up care following a cardiac arrest is very hit and miss across the UK. Working with sudden cardiac arrest UK (peer to peer support group) we know around 50% are not offered dedicated follow up / rehab / cardiac arrest support care (with worse long-term outcomes). BCIS will publish a recommendation of a minimum follow-up requirement once a patient with cardiac arrest has been discharged form a treating hospital in the UK regardless of cardiac arrest aetiology.

OTHER OHCA FOCUS GROUP WORKSTREAMS

1. To develop a BCIS recommended cardiac arrest centre (CAC) definition. This is likely to resemble definitions from Resuscitation to recovery document and ILCOR. How centres “become” a BCIS accredited CAC will have challenges, but implementation of the resuscitation to recovery document in taking OHCA patients to a CAC is likely to drive up standards of care. BCIS will develop Cardiology, emergency medicine, and intensive care OHCA champions to drive network solutions improving better specialised service provision.
2. To create a BCIS UK OHCA research collaborative able to test scientific hypotheses in the field of cardiac arrest.
3. Production of educational courses/materials for patients and health care professionals.

FOCUS GROUP ADVISORS

Dr Christian Napp (IC and ICU consultant, Hannover medical school, Germany) – advisor on integration of shock protocols and ECMO / percutaneous MCS.

Dr Guy Glover – Intensive care consultant (Guys and St Thomas)

Dr Max Damian – ICU neurologist and neuro-prognostication expert

PATIENT REPRESENTATIVES

Mr Paul Swindell – cardiac arrest survivor and founder of sudden cardiac arrest uk.org

Mr Forrest Wheeler – cardiac arrest survivor

GROUP MEMBERS