Regionalization of out-of-hospital cardiac arrest (OOHCA) care is a topic that is continuously evolving. Recently, there has been a large amount of investigation on the relationship between transport time and survivability. While regionalization of care has been shown to improve patient outcomes, there have been concerns about transport times needed to reach these centers.
According to the American Heart Association, one of the most common causes of OOHCA is acute coronary occlusion; early angiography or coronary intervention is recommended for patients with and without ST-segment elevation if a cardiac or coronary cause is suspected.1 Early CPR and defibrillation have drastically increased the rate of survival over the past few years, and successful OOHCA resuscitation by EMS is viewed as the norm and not the exception in today’s society.2 Recent data have shown that if patients are taken to a tertiary center, especially if it was a witnessed arrest, there was bystander CPR ongoing, or the initial rhythm was ventricular fibrillation, regardless of transport time, survival is improved. 3-5
In 2009, Spaite et al found that transport time was not associated with a decreased survival rate, supporting the safety of bypassing smaller, local hospitals to take patients to regional cardiac centers.6 In 2010, another study explored this question and concluded that survival to discharge was highest when OOHCA were taken to the more specialized hospitals, even though they were father away, and transport distance was not associated with survival. These findings were independent of patient characteristics.7 Another study in 2017 showed similar results, with increased survival to hospital discharge in those transported to an invasive heart center versus those who were not, despite transport time.8
While it is important to realize that the care provided to the OOHCA patient after arrival to the hospital is not unimportant or trivial, it is also well established that the two most significant variables associated with survival are excellent chest compressions and early defibrillation. EMS providers can easily perform these early interventions. As Cheskes et al demonstrated, high-quality chest compressions can be done regardless of location, despite the notion that CPR quality deteriorates during the transport phase.9 It is also known that cardiac arrest patients who do not achieve return of spontaneous circulation in the field have a lower chance of survival. Therefore, EMS plays an important role for the OOHCA patient.
Yet an important question still remains: What is an appropriate time for transport?