Improving access to extracorporeal membrane oxygenation for out of hospital cardiac arrest: pre-hospital ECPR and alternate delivery strategies

Abstract

Background The use of extracorporeal membrane oxygenation (ECPR) in refractory out-of-hospital cardiac arrest (OHCA) patients is usually implemented in-hospital. As survival in ECPR patients is critically time-dependent, alternative models in ECPR delivery could improve equity of access. Objectives To identify the best strategy of ECPR delivery to provide optimal patient access, to examine the time-sensitivity of ECPR on predicted survival and to model potential survival benefits from different delivery strategies of ECPR. Methods We used transport accessibility frameworks supported by comprehensive travel time data, population density data and empirical cardiac arrest time points to quantify the patient catchment areas of the existing in-hospital ECPR service and two alternative ECPR strategies: rendezvous strategy and pre-hospital ECPR in Sydney, Australia. Published survival rates at different time points to ECMO flow were applied to predict the potential survival benefit. Results With an in-hospital ECPR strategy for refractory OHCA, five hospitals in Sydney (Australia) had an effective catchment of 811,091 potential patients. This increases to 2,175,096 under a rendezvous strategy and 3,851,727 under the optimal pre-hospital strategy. Assuming earlier provision of ECMO flow, expected survival for eligible arrests will increase by nearly 6% with the rendezvous strategy and approximately 26% with pre-hospital ECPR when compared to the existing in-hospital strategy. Conclusion In-hospital ECPR provides the least equitable access to ECPR. Rendezvous and pre-hospital ECPR models substantially increased the catchment of eligible OHCA patients. Traffic and spatial modelling may provide a mechanism to design appropriate ECPR service delivery strategies and should be tested through clinical trials.

Novel and innovative resuscitation systems in Japan

“…To address this issue, prehospital ECPR in Utsunomiya is a good example of expanding geographical coverage and improving accessibility to ECPR for people living in the local community, as well as prehospital ECPR programs in other countries. 23 , 30 …”

Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest in Australia: a narrative review

“…The access of the current ECPR delivery system has been assessed using geographic information system and transport accessibility principles in Sydney 56 . This modelling reported that the current hospital‐based ECPR system for OHCA is the most inefficient in terms of patient access, with limited incremental value in patient access with the addition of more ECPR‐capable hospitals 56 .…”

“…The access of the current ECPR delivery system has been assessed using geographic information system and transport accessibility principles in Sydney 56 . This modelling reported that the current hospital‐based ECPR system for OHCA is the most inefficient in terms of patient access, with limited incremental value in patient access with the addition of more ECPR‐capable hospitals 56 . Alternative delivery methods, rendezvous and pre‐hospital ECPR were shown to significantly increase patient access (Box 7), even with the most conservative of models, with findings consistent with international modelling research 58,59 …”

“…The small blue islands represent where patients would have a survival benefit over conventional resuscitation assuming a time limit of one hour to implementation of ECPR support. (B) With the application of a single pre-hospital team in addition to the existing five hospitals, pre-hospital ECPR adds significant amount of coverage (green) and potential survival benefit57 Adapted and used with permission from Song et al56 ◆…”

Benefits, key protocol components, and considerations for successful implementation of extracorporeal cardiopulmonary resuscitation: a review of the recent literature

“…Several studies have suggested that the prehospital ECPR or rendezvous approach could allow more patients to receive ECPR than initiation on arrival to an ECPR-capable hospital [ 123 , 124 ]. Song et al [ 124 ] quantified patient catchment areas of the three approaches in Sydney, Australia, and reported that the rendezvous (n=2,175,096) and prehospital ECPR models (n=3,851,727) substantially increased the catchment of eligible patients with OHCA compared to the in-hospital ECPR model (n=811,091). However, implementation of ECPR using these approaches is challenging.…”