Anish K. Agarwal

Effect of Time of Day on Prehospital Care and Outcomes After Out-of-Hospital Cardiac Arrest

Background— More than 300 000 out-of-hospital cardiac arrests (OHCA) occur each year in the United States. The relationship between time of day and OHCA outcomes in the prehospital setting is unknown. Any such association may have important implications for emergency medical services resource allocation. Methods and Results— We performed a retrospective review of cardiac arrest data from a large, urban emergency medical services system. Included were OHCA occurring in adults from January 2008 to February 2012. Excluded were traumatic arrests and cases in which resuscitation measures were not performed. Day was defined as 8 AM to 7:59 PM; night, as 8 PM to 7:59 AM. A relative risk regression model was used to evaluate the association between time of day and prehospital return of spontaneous circulation and 30-day survival, with adjustment for clinically relevant predictors of survival. Among the 4789 included cases, 1962 (41.0%) occurred at night. Mean age was 63.8 years (SD, 17.4 years); 54.5% were male. Patients with an OHCA occurring at night did not have significantly lower rates of prehospital return of spontaneous circulation compared with patients having daytime arrests (11.6% versus 12.8%; P=0.20). However, rates of 30-day survival were significantly lower at night (8.56% versus 10.9%; P=0.02). After adjustment for demographics, presenting rhythm, field termination, duration of call, dispatch-to-scene interval, automated external defibrillator application, bystander cardiopulmonary resuscitation, and location, 30-day survival remained significantly higher after daytime OHCA, with a relative risk of 1.10 (95% confidence interval, 1.02–1.18). Conclusion— Rates of 30-day survival were significantly higher for OHCA occurring during the day compared with at night, even after adjustment for patient, event, and prehospital care differences.

Risk factors for mortality despite early protocolized resuscitation for severe sepsis and septic shock in the emergency department.

PURPOSE The purpose was to identify risk factors associated with in-hospital mortality among emergency department (ED) patients with severe sepsis and septic shock managed with early protocolized resuscitation. METHODS This was a retrospective, observational cohort study in an academic, tertiary care ED. We enrolled 411 adult patients with severe sepsis and lactate ≥4.0 mmol/L (n = 203) or septic shock (n = 208) who received protocolized resuscitation from 2005 to 2009. Emergency department variables, microbial cultures, and in-hospital outcomes were obtained from the medical record. Multivariable regression was used to identify factors independently associated with in-hospital mortality. RESULTS Mean age was 59.5 ± 16.3 years; 57% were male. Mean lactate was 4.8 mmol/L (3.5-6.7), 54% had positive cultures, and 27% received vasopressors in the ED. One hundred and five (26%) patients died in-hospital. Age, active cancer, do-not-resuscitate status on ED arrival, lack of fever, hypoglycemia, and intubation were independently associated with increased in-hospital mortality. Lactate clearance and diabetes were associated with a decreased risk of in-hospital death. CONCLUSIONS We identified a number of factors that were associated with in-hospital mortality among ED patients with severe sepsis or septic shock despite treatment with early protocolized resuscitation. These findings provide insights into aspects of early sepsis care that can be targets for future intervention.

The impact of emergency department crowding on early interventions and mortality in patients with severe sepsis

Objective Critically ill patients require significant time and care coordination in the emergency department (ED). We hypothesized that ED crowding would delay time to intravenous fluids and antibiotics, decrease utilization of protocolized care, and increase mortality for patients with severe sepsis or septic shock. Methods This was a retrospective cohort study of severe sepsis patients admitted to the hospital from the ED between January 2005 and February 2010. Associations between four validated measures of ED crowding (occupancy, waiting patients, admitted patients, and patient‐hours) assigned at triage, and time of day, time to antibiotics and fluids, and mortality were tested by analyzing trends across crowding quartiles. Results During the study period, 2913 severe sepsis patients were admitted to the hospital and 1127 (38.7%) qualified for protocolized care. In‐hospital mortality was 14.3% overall and 26% for patients qualifying for protocolized care. Time to IV fluids was delayed as ED occupancy rate increased and as patient hours increased. Time to antibiotics increased as occupancy rates, patient hours, and the number of boarding inpatients increased. Implementation rates of protocolized care decreased from 71.3% to 50.5% (p < 0.0001, OR 0.39) as the number of ED inpatient boarders increased; initiation of protocolized care was significantly higher as occupancy increased (OR 1.52). Mortality was unaffected by crowding parameters in all analyses. Conclusions With increased ED crowding, time to critical severe sepsis therapies significantly increased and protocolized care initiation decreased. As crowding increases, EDs must implement systems that optimize delivery of time‐sensitive therapies to critically ill patients.

Telemedicine REsuscitation and Arrest Trial (TREAT): A feasibility study of real-time provider-to-provider telemedicine for the care of critically ill patients

Background Protocol-based resuscitation strategies in the Emergency Department (ED) improve survival for out-of-hospital cardiac arrest (OHCA) and severe sepsis but implementation has been inconsistent. Objective To determine the feasibility of a real-time provider-to-provider telemedical intervention for the treatment of OHCA and severe sepsis. Materials and methods A three-center pilot study utilizing a “hub-spoke model” with an academic medical center acting both as the hub for teleconsultation as well as a spoke hospital enrolling patients. Eligible patients were adults presenting with either return of spontaneous circulation (ROSC) following OHCA or with severe sepsis. Telemedical encounters were monitored for quality of interface and patient level data (demographics, physiologic, laboratory, treatment) were abstracted. Results Over a 12-week period, there were 80 text alerts. Of 38 OHCA alerts, 13 achieved ROSC (34.2%), 85% underwent teleconsultation (11/13). Of 42 “lactate ≥4 mmol/L” alerts, 33.3% (14/42) were determined to have severe sepsis and underwent teleconsultation. Mean time from OHCA teleconsultation request to live connection: 3.7 min (95% CI 1.6–5.8); mean call duration: 71.7 min (95% CI 34.6–108.8). Mean time from sepsis teleconsultation request to connection: 8.4 min (95% CI 4.5–12.3); mean call duration: 61.5 min (95% CI 37.2–85.8). Discussion Telemedicine provides a robust and reliable means of quickly bringing expertise virtually to the bedside at the most proximal point in a patient’s hospital care. Conclusions Real time ED-based telemedical consultation for patients with ROSC after OHCA or severe sepsis has the potential to improve the dissemination and implementation of evidence-based care.

Adult out-of-hospital cardiac arrest in philadelphia from 2008–2012: An epidemiological study

BACKGROUND Wide variation in out-of-hospital cardiac arrest (OHCA) survival has been reported, with low survival in urban settings. We sought to describe the epidemiology of OHCA in Philadelphia, Pennsylvania, the fifth largest U.S. city, and identify potential areas for targeted interventions to improve survival. METHODS AND RESULTS Retrospective chart review of adult, non-traumatic, OHCA occurring in Philadelphia between 2008 and 2012. We determined incidence and epidemiological factors including: demographics, initial cardiac rhythm, bystander cardiopulmonary resuscitation, automated external defibrillator use, return of spontaneous circulation and 30-day survival. 5198 cases of adult, non-traumatic OHCA were identified. The incidence was 81.5/100,000. The majority of cases occurred in a residence (76.2%); 30.4% were witnessed events; the initial cardiac rhythm was pulseless ventricular tachycardia or ventricular fibrillation in 6.2% of cases, pulseless electrical activity in 21.0%, asystole in 38.3% and was unknown or undocumented in the remaining 34.5%. Multivariate logistic regression analysis demonstrated increased 30-day survival with younger age, shockable cardiac rhythms, and daytime arrest. 30-day survival was 8.1% for EMS-assessed patients and 8.6% for EMS-transported patients. CONCLUSIONS Philadelphias reported incidence is consistent with urban settings although the survival rate is higher than other urban centers.