With an emergency department (ED) that receives the most out of hospital cardiac arrest (OOHA) patients by ambulance in Queensland, PA Hospital (PAH) is well placed to drive better patient outcomes - a new study is looking to do just that.
Made possible by the PA Research Foundation, the research is led by PAH clinician Dr Kim Gill and will use retrospective Queensland Ambulance data of 650 patients brought into the ED having suffered from a cardiac arrest to review emergency department outcomes from 2017 to 2022.
The project’s aim is to add to current literature on emergency department outcomes and help inform clinicians about current practices and whether they are optimal for patient survival and rehabilitation.
Building upon a study of 250 patients, Dr Gill said the importance of the data is the fact that cardiac arrest is still the number one cause of death in Australia, and that PAH receives close to all out of hospital cardiac arrest patients for Brisbane’s south side.
“We have the trauma data and the databases, which collect a lot of information about what we do in the emergency department for our trauma patients, but we don't have that for our acute resuscitation patients and cardiac arrested patients,” she said.
“With this study we want to see if we are collecting the right data points to build a data registry, then we want to align that to the advanced life support algorithms that are instituted by the advanced resuscitation council.
“The council has algorithms that healthcare practitioners should follow, and the data will allow us to see whether we are following those guidelines correctly for each patient, to do resuscitation the right way for the best outcomes.
“The advanced life support algorithm we follow is essentially identifying whether it's a shockable rhythm or a non-shockable rhythm. If it's shockable, we shock them and then we provide chest compressions for two minutes and then give drugs after two minutes.
“If it's not a shockable rhythm, we give medications and identify the causes and try and reverse the causes of the arrest.”
“Whilst we are performing cardio-pulmonary resuscitation and advanced life support we are also looking to diagnose the cause of cardiac arrest and rapidly institute treatment to prevent further end organ damage and commence neuroprotective measures early in their ED care.”
While there is more extensive research within the pre-hospital and ICU setting, there is to date limited studies in emergency management, which is potentially as or more important, as the ED is the first point of care outside the ambulance for the patient and how they fare can determine the patient's prognosis and ongoing care.
Dr Gill hopes the work will enable ED clinicians to be better informed about a patient’s prognosis and in turn be able to relay that information clearly to families and loved ones.
“What got me interested in the first place was that patients were coming into the department having had an arrest and then I would have to go and talk to their family, she said.”
“I didn't really have a full understanding of their potential outcomes and I would be very pessimistic, and I’d just say, ‘this is a very serious situation’ and we couldn't put any numbers to that, and I would be very bleak about the situation.
“Generally, families want to know three things when I talk with them in the ED. What has happened and why? Will their loved one survive? Will their loved one be left with permanent disability and all the ramifications of that.
“First of all, defining what a cardiac arrest is and being able to explain that to the family as well as what has happened to their loved one, that their heart has stopped, is very important. We can then tell them what we have done for their loved one and what we have found as to what caused their arrest.
“We then want to be able to tell them with some degree of certainty what might happen to their loved one, where the patient would go to after their emergency department care and their potential prognosis from here at the PA Hospital.
“Having done our pilot study, I can answer these questions with a little more certainty. We found that if someone gets to the PA with a pulse after suffering an OOHCA, they might still be unconscious, but they have a pulse, they have a 54% chance of surviving their hospital stay.
“We also saw that “If they survive here at PA, the majority of patients do so with a good neurological outcome, and will generally go home to their usual place of residence rather than be left in a vegetative stat. This is such important information because that's what people( patients and families)want to know.
“Up front, where I could, I was able to give them more detailed information. It's all individual and you don't know what's going to happen to each patient, but I can now say that half of the people who come in with a pulse, their outcome is good. It is a much better conversation to have than ‘I have no idea what's going to happen to your loved one, we just have to wait and see’.”
The study may also determine whether a process called extra corporal life support (ECPR) which is currently being trialed at Royal Brisbane would be applicable and beneficial for the PA’s patients.
ECPR involves putting the heart on a bypass system, like what occurs in surgical theatres, where support is provided to other vital organs. Patients can then be transported to the catheterization laboratory for further assessment and treatment without further organ damage.
“ECPR is new technology and we're still trying to work out the timing of when to institute it after an OOHCA. At PA, we've taken a slightly different approach, because currently, it has been determined that the survival rates don't justify the resources to be invested in an ECPR service, for our health district,” Dr Gill said.
“Nobody has really studied what we do in the emergency department for patients who have suffered an OHCA, let alone the effects of introducing ECPR.
“We want to know if there’s anything we can improve already without ECPR, or do we need to think about bringing it in? Without data to compare, we're never going to know that answer. The two questions that we need to answer are, what is the benchmark for ED outcomes for patients who have suffered an out of hospital cardiac arrest and is ECPR an option for the Metro South Health service district ?”