Cardiac Arrest Centers May Improve Survival
By Bruce Jancin
Elsevier Global Medical News
NEW ORLEANS -- The level 1 cardiac arrest center is an innovation that not only increases hospital discharge rates after out-of-hospital sudden cardiac arrest but also serves as a substantial institutional profit center, according to a new study.
Level 1 cardiac arrest centers are analogous to regional level 1 trauma centers. The concept is that coordinated, specialized, multidimensional care improves clinical outcomes in gravely ill patients.
At the first level 1 cardiac arrest center, implemented at St. Cloud (Minn.) Hospital, the result has been a 50% increase in the hospital discharge rate and a net profit margin of more than $20,000 for every patient discharged alive, Dr. Keith G. Lurie reported at the annual scientific sessions of the American Heart Association.
Among the key elements of care provided at the level 1 cardiac arrest centers springing up around the country are emergent percutaneous coronary intervention, rapid hypothermia of patients who are comatose or unable to respond appropriately upon arrival at the hospital, optimal management in an ICU, electrophysiologic evaluation along with placement of an implantable cardioverter-defibrillator if warranted, and aggressive risk-reduction measures, explained Dr. Lurie, a cardiac electrophysiologist who is professor of medicine and emergency medicine at the University of Minnesota, Minneapolis.
Dr. Lurie also is a cofounder of Take Heart America, a demonstration project designed to show that a comprehensive, community-wide approach that embraces all of the strongest recommendations contained in the 2005 AHA resuscitation guidelines can markedly increase out-of-hospital cardiac arrest survival rates. The project (www.takeheartamerica.org) is ongoing in St. Cloud; Austin, Tex.; Anoka County, Minn.; and Columbus, Ohio.
The level 1 cardiac arrest center is the inpatient element of Take Heart America. The community aspect includes promotion of bystander CPR through aggressive CPR training, especially in schools and businesses, as well as widespread placement of automated external defibrillators in public places and schools.
Also, EMS personnel are retrained in state-of-the-art resuscitation methods designed to enhance circulation, including use of impedance threshold devices, performing CPR before and after a single shock defibrillation, use of the LUCAS (Lund University Cardiopulmonary Assist System) automated CPR device to provide good-quality CPR while a patient is being moved, and intraosseous drug infusion when an intravenous line can't quickly be placed.
These out-of-hospital interventions have led to markedly increased rates of survival during the first 24 hours post-cardiac arrest. But most of these new survivors were dying in the hospital after the 24-hour mark. That was the impetus for creating level 1 cardiac arrest centers.
St. Cloud Hospital is a regional referral center in central Minnesota with a catchment area of roughly 500,000 people. In the year before launch of the level 1 cardiac arrest center, 33 patients were admitted to the hospital alive with a pulse following out-of-hospital cardiac arrest; 11 left the hospital alive.
In contrast, in the first 19 months after the December 2005 introduction of the level 1 cardiac arrest center, 104 patients with a pulse were brought in by ambulance and airlift, 54 of whom survived to discharge. That's a 52% discharge rate, well over twice the national average, and significantly higher than the 33% rate in the local historic controls.
"It's fantastic. We've had so many survivors in central Minnesota that the level 1 center's first survivor has started a survivor network there. They share their experiences, teach CPR in the schools, and advocate for better care for patients with heart disease," Dr. Lurie said in an interview.
Moreover, a high-level administrator at St. Cloud State University who survived his out-of-hospital cardiac arrest was inspired to help Dr. Lurie and colleagues start a program called CPR Goes to College.
"All students at St. Cloud State are being trained in how to do CPR as part of a widespread bystander CPR awareness campaign," he said.
Although he did not present specific data on survivors' neurologic outcomes, Dr. Lurie said most patients who survived to leave the hospital were doing pretty well neurologically.
Dr. Lurie presented a cost-effectiveness analysis of 69 patients treated at the level 1 cardiac arrest center. The hospital collected an average of $57,783 in billings per treated patient. After subtracting the direct costs of care, the hospital was left with an average net direct margin of $20,684 per survivor and $3,329 per nonsurvivor.
"This is a nonprofit hospital. In a for-profit hospital, this money would be pure profit for the hospital," he noted.
Dr. Lurie recalled that getting the hospital to approve the level 1 cardiac arrest center was a protracted political struggle. Administrators were particularly resistant to the idea of laying out $25,000 for a rapid cooling system. His first clue that the center was making money for the hospital rather than running in the red came when the hospital purchased a second $25,000 hypothermia system within 3 months of the center's opening.
The improved survival rates and financial benefits documented at St. Cloud Hospital have been replicated at the other level 1 cardiac arrest centers participating in Take Heart America. Level 1 centers also have been started in Ann Arbor, Mich., and Oshkosh, Wisc.; at William Beaumont Hospital in Royal Oak, Mich.; and in Washington state.
"By taking this comprehensive approach, we've basically doubled survival rates in all patients following out-of-hospital cardiac arrest in the communities where we've deployed Take Heart America, from 9%--which was already twice the national average--up to 17%," Dr. Lurie observed.
More than 300,000 Americans per year die of sudden cardiac arrest.
Take Heart America is financed by more than a dozen hospital foundations and corporate contributors. Among them is Advanced Circulatory Systems Inc., where Dr. Lurie is chief medical officer. He is the inventor of the company's ResQPOD, a noninvasive impedance threshold device widely used in CPR.