Debate is on: On-site vs. hospital treatment for cardiac arrest

To transport to hospital or not when an out-of-hospital cardiac arrest has no shockable rhythm was at the center of a debate published online Sept. 23 in BMJ.

Appropriate use of emergency and hospital services was a large part of the contention between the authors.

Bruce D. Adams, MD, of the University of Texas Health Sciences Center in San Antonio, wrote that more cases are recoverable once at the hospital than the Basic Life Support Termination of Resuscitation (BLS-TOR) rule considers. Largely, Adams noted that survival in these patients was tied directly to speedy delivery to quality hospital treatment.

As the rule tends to be location-sensitive, Adams noted that some regions do more poorly based on already poor predicted outcomes of cardioplumonary resusciation (CPR). “At the extreme, if you apply BLS-TOR to the late residents of Highgate cemetery, you would achieve a positive predictive value of 100%,” Adams wrote.

Adams also noted that applying this rule to every case would have led to higher losses, particularly in areas outside of North America, where as a test, BLS-TOR becomes less specific.

Meanwhile, Jonathan Benger, BSc, MBChB, MD, of the University of the West of England in Bristol, wrote that more good could be done by not interrupting CPR and defibrillation on site even for the length of time to get a patient into transport. Benger noted that with advances to available ambulance services, more specialized equipment was available for use on site to treat a patient once help arrived.

Further, interrupting care to bring the patient into the ambulance and perform aid enroute could in fact be fatal. As point to this case, Benger wrote that the impulse to scoop up a child and drive to the nearest hospital “may paradoxically deny the child the optimal chest compressions and oxygenation that he or she desperately needs and which have the greatest chance of success when delivered immediately rather than in the back of a moving ambulance or on arrival at hospital.”

Benger wrote that few cardiac arrest cases, such as those drug overdose or hypothermia, that involve transport to hospital change the outcome for patients if circulation did not return with on-site assistance.

Adams argued that considering to bring patients to a hospital should not be a cost issue, noting that in the U.S., the number of emergency room deaths from patients with out-of-hospital cardiac arrests were less than 0.1 percent of the annual losses to Medicare from fraudulent claims.

Benger, on the hand, wrote that empowering emergency personnel to work with the advances they have available to them is, in and of itself, more effective in delivering better care than racing through streets.

Adams countered that in order to prevent one injury by way of an ambulance accident, 2,178 calls would not be responded to, leading to more deaths, not fewer. Further, he noted, that 5 percent of all organs harvested are from patients who would have been brought to the hospital whether on-site and ambulance treatment was successful.

Both recognized that doing nothing leads to patient death. The debate highlighted the issues of when, where, by whom and with what technology treatment is most effective.