Current Use, Capacity, and Perceived Barriers to the Use of Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest in Canada

Abstract

Background Extracorporeal cardiopulmonary resuscitation (ECPR) is a therapeutic option for refractory cardiac arrest. We sought to perform an environmental scan to describe ECPR utilization in Canada and perceived barriers for application to out-of-hospital cardiac arrest (OHCA). Methods This was a national cross-sectional study. We identified all cardiovascular surgery- and extracorporeal membrane oxygenation (ECMO)-capable hospitals in Canada and emergency medical services (EMS) agencies delivering patients to those centres. We requested the medical lead from each hospital’s ECMO service and each EMS agency to submit data regarding ECMO and ECPR utilization, as well as perceived barriers to ECPR provision for OHCA. Results We identified and received survey data from 39 of 39 Canadian hospital institutions and 21 of 22 EMS agencies. Of hospitals, 38 (97%) perform ECMO and 27 (69%) perform ECPR (74% of which perform ≤5 cases per year). Of the 18 (46%) sites offering ECPR for OHCA, 8 apply a formal protocol for eligibility and initiation procedures. EMS agencies demonstrate heterogeneity with intra-arrest transport practices. The primary rationale for nontransport of refractory OHCA is that hospital-based care offers no additional therapies. Perceived barriers to the use of ECPR for OHCA were primarily related to limited evidence supporting its use, rather than resources required. Conclusion Many Canadian cardiovascular surgery- or ECMO-equipped hospitals use ECPR; roughly half employ ECPR for OHCAs. Low case volumes and few formal protocols indicate that this is not a standardized therapy option in most centres. Increased application may be dependent on a stronger evidence base including data from randomized clinical trials currently underway.

CEPP: Canadian Extracorporeal Life Support (ECLS) Protocol Project

“…There are 39 institutions in Canada capable of delivering ECLS. 4 Program documentation was obtained from 13 (33%) institutions representing all provinces, two of four (50%) lung/heart transplant centres, five of 11 (45%) heart transplant centres (without lung transplant), and six of 24 (25%) cardiac surgery-only centers. Documents provided varied between centers and included practice J o u r n a l P r e -p r o o f 13 guidelines, protocols, policy and procedures, and order sets.…”

“…The prevalence of key elements in documentation varied across centres, with J o u r n a l P r e -p r o o f a higher prevalence found in centres with heart and/or lung transplant programs. Given that the majority of ECLS cases are done at lower volume centres in Canada, 4 and lower volume centres have been shown to have worse outcomes, 5 this study identified potential areas for quality improvement initiatives aimed at increasing protocol completeness and harmonization across institutions.…”

“…ECPR). 4 For centres with protocols, there are limited data to guide which elements should be included and their implementation. [10][11][12] Better characterization of existing protocols and understanding their usage within Canadian programs could improve ECLS service delivery across the nation.…”

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest - who, when, and where?

“…Data from the Extracorporeal Life Support Organization Registry demonstrated an 10-fold increase in ECPR utilization during the past decade [5]. However, less than 50% of centers performing ECPR for OHCA in Canada have a formal protocol, with only 21% offering the service 24 h a day [6 ▪ ]. Although there is no global consensus on inclusion criteria for ECPR, previous studies estimated that approximately 11% of patients suffering OHCA could be candidates for ECPR [7].…”

“…Among the existing protocols, the upper limit of age cutoffs varied between 65 and 80years old [6 ▪ ].…”