Implementation of the Fifth Link of the Chain of Survival Concept for Out-of-Hospital Cardiac Arrest

Background—The American Heart Association 2010 resuscitation guidelines recommended adding a fifth link (multidisciplinary postresuscitation care in a regional center) to the previous 4 in the chain of survival concept for out-of-hospital cardiac arrest. Our study aimed to determine the effectiveness of this fifth link. Methods and Results—This multicenter prospective cohort study involved all eligible out-of-hospital cardiac arrest patients in the Aizu region (n 1482, suburban/rural, Fukushima, Japan). Proportions of favorable neurological outcomes were evaluated before (January 2006–April 2008) and after (January 2009–December 2010) the implementation of the fifth link. After implementation, all patients were transported directly from the field to the tertiary-level hospital or secondarily from an outlying hospital to the tertiary-level hospital after restoration of circulation. The tertiary hospital provided intensive postresuscitation care, including appropriate hemodynamic and respiratory management, therapeutic hypothermia, and percutaneous coronary intervention. One-month survival with a favorable neurological outcome among all patients treated by emergency medical services providers improved significantly after implementation (4 of 770 [0.5%] versus 21 of 712 [3.0%]; P 0.001). The adjusted odds ratios of favorable neurological outcome were 0.9 (95% confidence interval, 0.7–1.1) for early access to emergency medical care, 3.1 (95% confidence interval, 0.7–14.2) for bystander resuscitation, 14.7 (95% confidence interval, 3.2–67.0) for early defibrillation, 1.0 (95% confidence interval, 1.0–1.1) for early advanced life support, and 7.8 (95% confidence interval, 1.6–39.0) for the fifth link. Conclusion—The proportion of out-of-hospital cardiac arrest patients with a favorable neurological outcome improved significantly after the implementation of the fifth link, which may be an independent predictor of outcome. Clinical Trial Registration—URL: http://www.apps.who.int/trialsearch. Unique identifier: UMIN000001607. (Circulation. 2012;126:589-597.)

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