Comprehensive simulation training for E-CPR improves the 1-year mortality of patients with refractory cardiac arrest
Authors: Inamori T , Unoki T , Tsurusaki Y , Nakayama T , Toyofuku T , Konami Y , Suzuyama H , Inoue M , Horio E , Kodama K , Taguchi E , Sawamura T , Sakamoto T , Nakao K , Koyama J 
Published: November 2023

Abstract

Background
Extracorporeal cardiopulmonary resuscitation (E-CPR) has been utilized as a rescue strategy for patients with refractory cardiac arrest (CA). The collapse to ECMO initiation time (CTET) has a strong correlation with survival, but decisions of initiating E-CPR are sometimes difficult to make and the opportunities for developing teamwork skills are limited. Therefore, to improve the outcome of E-CPR, we developed a comprehensive simulation-based E-CPR training program.

Purpose
In the present study we assessed whether the E-CPR training improved the mortality and the neurological outcome.

Methods
E-CPR simulation training program was carried out twice a year to the medical team using a mock vascular model since October 2017. We enrolled 177 consecutive patients who underwent E-CPR from January 2012 to January 2022. The patients were divided into two groups: the pre-simulation and the post-simulation. The outcome was CTET, 1-year mortality and favorable neurological outcomes defined as cerebral performance categories (CPC) of 1 or 2 at hospital discharge.

Results
There were 86 patients in the Pre-simulation group and 91 patients in the Post-simulation group. No differences were found in age, rates of witnessed CA and bystander-CPR, shockable rhythms, or acute coronary syndrome (ACS). The frequency of use of the intra-aortic balloon pump was significantly higher in the Pre-simulation group compared to the Post-simulation group (74% vs. 23%; p &lt;0.001), while the Impella device was only used in the Post-simulation group (46%), due to its availability in our institution since October 2017. Compared to Pre-simulation group, the CTET was significantly shorter (44 minutes vs. 33 minutes; p = 0.001), and the Kaplan-Meier analysis for 1-year survival was significantly higher with the Post-simulation group (12% vs. 23%; p = 0.02 by log-rank test). The rate of favorable neurological outcome was not significantly different between the two groups. However, when patients were analyzed separately by in-hospital CA (IHCA) and out-of-hospital CA (OHCA), no significant difference was observed in IHCA, whereas OHCA demonstrated a significant reduction in both door to ECMO initiation time and CTET, leading to a significant improvement in neurological outcome (3% vs. 20%; p = 0.04). Multivariate cox proportional hazard analysis revealed that age (hazard ratio [HR], 1.22 [10 years increase]; 95% confidence interval [CI], 1.07-1.41, p = 0.004), initial shockable rhythm (HR, 0.61; 95%CI 0.41-0.91, p = 0.01), combined use of Impella (HR, 0.59; 95% CI, 0.37–0.98, p = 0.02), and CTET (HR, 1.02, 95%CI, 1.01-1.03, p &lt;0.0001) were significantly associated with the 1-year mortality.

Conclusions
The E-CPR training significantly improved the collapse to ECMO time. The faster deployment of ECMO increased the 1-year survival rate in patients with refractory CA. Additionally, the use of Impella (ECPELLA) may have improved the survival rate.The effect of simulation trainingKaplan-Meier analysis