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Therapeutic hypothermia, the standard for post-resuscitation care of out-of-hospital sudden cardiac arrest (SCA), is an area that the most recent resuscitation guidelines note ''has not been studied adequately.'' We conducted a two-phase study examining the role of intra-arrest hypothermia for out-of-hospital SCA, first standardizing the resuscitation and transport of patients to resuscitation centers where post-resuscitation hypothermia was required and then initiating hypothermia during out-of-hospital resuscitation efforts. The primary end points were return of spontaneous circulation (ROSC), sustained ROSC, survival to hospital admission, and survival to discharge. Comparing the cohort of standard hospital-initiated hypothermia (Phase I) with the prehospital-initiated hypothermia via large-volume ice-cold saline (LVICS) infusion (Phase II), no difference was noted for any end point: ROSC (56.4% vs. 53.4%, p = 0.51; 95% confidence interval [CI]:-5.7 to 11.4), sustained ROSC (46.9% vs. 42.8%, p = 0.38; 95% CI:-4.7 to 12.4), hospital admission (44.7% vs. 37.7%, p = 0.13; 95% CI:-1.9 to 15.4), hospital discharge among those surviving to admission (40.0% vs. 28.0%, p = 0.08; 95% CI:-1.5 to 27.8), or neurological outcome among those surviving to discharge (76.0% vs. 71.4%, p = 0.73; 95% CI:-26.9 to 38.7). Patients presenting in ventricular fibrillation were more likely to survive to hospital discharge in both phases, although a trend toward worsened early outcomes (ROSC, sustained ROSC, and survival to admission) with intra-arrest hypothermia was noted in this subgroup. Multivariable regression analyses failed to demonstrate any survival benefit associated with the intra-arrest initiation of hypothermia via LVICS. Our study, the largest study of intra-arrest initiation of hypothermia published to date, failed to demonstrate any effect on survival for out-of-hospital SCA patients, confirming findings of previously published smaller studies. We therefore do not recommend the use of intra-arrest cooling via LVICS infusion as part of routine out-of-hospital SCA resuscitative efforts.

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Purpose The Centers for Medicare and Medicaid Services (CMS) and the American College of Emergency Physicians (ACEP) developed national quality measures for emergency department (ED) sepsis care. Like care for many conditions, meeting sepsis quality metrics can vary between settings. We sought to examine and compare sepsis care quality in rural vs urban hospital‐based EDs. Methods We analyzed data from EDs participating in the national Emergency Quality Network (E‐QUAL). We collected preliminary performance data on both the CMS measure (SEP‐1) and the ACEP measures via manual chart review. We analyzed SEP‐1 data at the hospital level based on existing CMS definitions and analyzed ACEP measure data at the patient level. We report descriptive statistics of performance variation in rural and urban EDs. Findings Rural EDs comprised 58 of the EDs reporting SEP‐1 results and 405 rural patient charts in the manual review. Of sites reporting SEP‐1 results, 44% were rural and demonstrated better aggregate SEP‐1 bundle adherence than urban EDs (79% vs 71%; P = .049). Both urban and rural hospitals reported high levels of compliance with the ACEP recommended initial actions of obtaining lactate and blood cultures, with urban EDs outperforming rural EDs on metrics of IV fluid administration and antibiotics (74% urban vs 60% rural; P ≤  .001; 91% urban vs 84% rural; P ≤  .001, respectively). Conclusions Sepsis care at both rural and urban EDs often achieves success with national metrics. However, performance on individual components of ED sepsis care demonstrates opportunities for improved processes of care at rural EDs.