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Original Investigation
September 15, 2020

Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest

Author Affiliations
  • 1Departments of Emergency Medicine and the Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, Canada
  • 2University of British Columbia, Vancouver, Canada
  • 3Department of Medicine, University of Washington, Seattle
  • 4Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 5Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
  • 6Li Ka Shing Knowledge Institute, St Michael’s Hospital, Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Canada
  • 7Oregon Health and Science University, Portland
  • 8Metropolitan Area EMS Authority/Emergency Physicians Advisory Board, Ft Worth, Texas
JAMA. 2020;324(11):1058-1067. doi:10.1001/jama.2020.14185
Key Points

Question  Is transport to hospital during adult out-of-hospital cardiac arrest resuscitation compared with continued on-scene treatment associated with a difference in survival to hospital discharge?

Findings  In this cohort study that used a time-dependent propensity score–matched analysis including 27 705 patients with out-of-hospital cardiac arrest, intra-arrest transport compared with continued on-scene resuscitation had a probability of survival to hospital discharge of 4.0% vs 8.5%, a difference that was statistically significant.

Meaning  These results do not support the practice of routinely transporting patients during resuscitation from out-of-hospital cardiac arrest to the hospital.

Abstract

Importance  There is wide variability among emergency medical systems (EMS) with respect to transport to hospital during out-of-hospital cardiac arrest (OHCA) resuscitative efforts. The benefit of intra-arrest transport during resuscitation compared with continued on-scene resuscitation is unclear.

Objective  To determine whether intra-arrest transport compared with continued on-scene resuscitation is associated with survival to hospital discharge among patients experiencing OHCA.

Design, Setting, and Participants  Cohort study of prospectively collected consecutive nontraumatic adult EMS-treated OHCA data from the Resuscitation Outcomes Consortium (ROC) Cardiac Epidemiologic Registry (enrollment, April 2011-June 2015 from 10 North American sites; follow-up until the date of hospital discharge or death [regardless of when either event occurred]). Patients treated with intra-arrest transport (exposed) were matched with patients in refractory arrest (at risk of intra-arrest transport) at that same time (unexposed), using a time-dependent propensity score. Subgroups categorized by initial cardiac rhythm and EMS-witnessed cardiac arrests were analyzed.

Exposures  Intra-arrest transport (transport initiated prior to return of spontaneous circulation), compared with continued on-scene resuscitation.

Main Outcomes and Measures  The primary outcome was survival to hospital discharge, and the secondary outcome was survival with favorable neurological outcome (modified Rankin scale <3) at hospital discharge.

Results  The full cohort included 43 969 patients with a median age of 67 years (interquartile range, 55-80), 37% were women, 86% of cardiac arrests occurred in a private location, 49% were bystander- or EMS-witnessed, 22% had initial shockable rhythms, 97% were treated by out-of-hospital advanced life support, and 26% underwent intra-arrest transport. Survival to hospital discharge was 3.8% for patients who underwent intra-arrest transport and 12.6% for those who received on-scene resuscitation. In the propensity-matched cohort, which included 27 705 patients, survival to hospital discharge occurred in 4.0% of patients who underwent intra-arrest transport vs 8.5% who received on-scene resuscitation (risk difference, 4.6% [95% CI, 4.0%- 5.1%]). Favorable neurological outcome occurred in 2.9% of patients who underwent intra-arrest transport vs 7.1% who received on-scene resuscitation (risk difference, 4.2% [95% CI, 3.5%-4.9%]). Subgroups of initial shockable and nonshockable rhythms as well as EMS-witnessed and unwitnessed cardiac arrests all had a significant association between intra-arrest transport and lower probability of survival to hospital discharge.

Conclusions and Relevance  Among patients experiencing out-of-hospital cardiac arrest, intra-arrest transport to hospital compared with continued on-scene resuscitation was associated with lower probability of survival to hospital discharge. Study findings are limited by potential confounding due to observational design.

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