Decision-tree model for predicting outcomes after out-of-hospital cardiac arrest in the emergency department

Critical Care

Yumiko Goto¹  Tetsuo Maeda²  Yoshikazu Goto² 

[1] Department of Cardiology, Yawata Medical Center, 12-7 I Yawata, Komatsu 923-8551, Japan;Section of Emergency Medicine, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa 920-8641, Japan

关键词: prediction model;    outcome;    emergency department;    cardiopulmonary resuscitation;    cardiac arrest;   

Others  :  818049
DOI  :  10.1186/cc12812

 received in 2012-12-14, accepted in 2013-07-11,  发布年份 2013

【 摘 要 】

Introduction

Estimation of outcomes in patients after out-of-hospital cardiac arrest (OHCA) soon after arrival at the hospital may help clinicians guide in-hospital strategies, particularly in the emergency department. This study aimed to develop a simple and generally applicable bedside model for predicting outcomes after cardiac arrest.

Methods

We analyzed data for 390,226 adult patients who had undergone OHCA, from a prospectively recorded nationwide Utstein-style Japanese database for 2005 through 2009. The primary end point was survival with favorable neurologic outcome (cerebral performance category (CPC) scale, categories 1 to 2 [CPC 1 to 2]) at 1 month. The secondary end point was survival at 1 month. We developed a decision-tree prediction model by using data from a 4-year period (2005 through 2008, n = 307,896), with validation by using external data from 2009 (n = 82,330).

Results

Recursive partitioning analysis of the development cohort for 10 predictors indicated that the best single predictor for survival and CPC 1 to 2 was shockable initial rhythm. The next predictors for patients with shockable initial rhythm were age (<70 years) followed by witnessed arrest and age (

>

70 years) followed by arrest witnessed by emergency medical services (EMS) personnel. For patients with unshockable initial rhythm, the next best predictor was witnessed arrest. A simple decision-tree prediction mode permitted stratification into four prediction groups: good, moderately good, poor, and absolutely poor. This model identified patient groups with a range from 1.2% to 30.2% for survival and from 0.3% to 23.2% for CPC 1 to 2 probabilities. Similar results were observed when this model was applied to the validation cohort.

Conclusions

On the basis of a decision-tree prediction model using four prehospital variables (shockable initial rhythm, age, witnessed arrest, and witnessed by EMS personnel), OHCA patients can be readily stratified into the four groups (good, moderately good, poor, and absolutely poor) that help predict both survival at 1 month and survival with favorable neurologic outcome at 1 month. This simple prediction model may provide clinicians with a practical bedside tool for the OHCA patient's stratification in the emergency department.

【 授权许可】

   
2013 Goto et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

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【 参考文献 】

• [1]Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Hiraide A, for the Implementation Working Group for All-Japan Utstein Registry of the Fire and Disaster Management Agency: Nationwide public access defibrillation in Japan. N Engl J Med 2010, 362:994-1004.
• [2]Kitamura T, Iwami T, Kawamura T, Nitta M, Nagao K, Nonogi H, Yonemoto N, Kimura T, for the JCS-ReSS Study Group: Nationwide improvements in survival from out-of-hospital cardiac arrest in Japan. Circulation 2012, 126:2834-2843.
• [3]Sasson C, Rogers MAM, Dahl J, Kellermann AL: Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010, 3:63-81.
• [4]Nielsen N: Predictive scores, friend or foe for the cardiac patient. Resuscitation 2012, 83:669-670.
• [5]Adrie C, Cariou A, Mourvillier B, Laurent I, Dabbane H, Hantala F, Rhaoui A, Thuong M, Monchi M: Predicting survival with good neurological recovery at hospital admission after successful resuscitation of out-of-hospital cardiac arrest: the OHCA score. Eur Heart J 2006, 27:2840-2845.
• [6]Hayakawa K, Tasaki O, Hamasaki T, Sakai T, Shiozaki T, Nakagawa Y, Ogura H, Kuwagata Y, Kajino K, Iwami T, Nishiuchi T, Hayashi Y, Hiraide A, Sugimoto H, Shimazu T: Prognostic indicators and outcome prediction model for patients with return of spontaneous circulation from cardiopulmonary arrest: the Utstein Osaka Project. Resuscitation 2011, 82:874-880.
• [7]Rittenberger JC, Tisherman SA, Holm MB, Guyette FX, Callaway CW: An early, novel illness severity score to predict outcome after cardiac arrest. Resuscitation 2011, 82:1399-1404.
• [8]Okada K, Ohde S, Otani N, Sera T, Mochizuki T, Aoki M, Ishimatsu S: Prediction protocol for neurological outcome for survivors of out-of-hospital cardiac arrest treated with targeted temperature management. Resuscitation 2012, 83:734-739.
• [9]Gräsner JT, Meyborm P, Lefering R, Wnent J, Bahr Jan, Messelken M, Hantzen T, Franz R, Scholz J, Scheppers A, Böttiger BW, Bein B, Fischer M, the German Resuscitation Registry Study Group: ROSC after cardiac arrest: the RACA score to predict outcome after out-of-hospital cardiac arrest. Eur Heart J 2011, 32:1649-1656.
• [10]Yasunaga H, Miyata H, Horiguch H, Tanabe S, Akahane M, Ogawa T, Koike S, Imamura T: Polulation density, call-response interval, and survival of out-of-hospital cardiac arrest. Int J Health Geogr 2011, 10:26. BioMed Central Full Text
• [11]Akahane M, Ogawa T, Koike S, Tanabe S, Horiguchi H, Mizoguchi T, Yasunaga H, Imamura T: The effects of sex on out-of-hospital cardiac arrest outcomes. Am J Med 2011, 124:325-333.
• [12]Morrison LJ, Visentin LM, Kiss A, Theriault R, Eby D, Vermeulen M, Sherbino J, Verbeek PR, TOR Investigators: Validation of a rule for termination in out-of-hospital cardiac arrest. N Engl J Med 2006, 355:478-487.
• [13]Skrifvars MB, Vayrynen T, Kuisma M, Castren M, Parr MJ, Silfverstople J, Svensson L, Jonsson L, Herlitz J: Comparison of Helsinki and European Resuscitation Council "do not attempt resuscitation" guidelines, and a termination of resuscitation clinical prediction rule for out-of-hospital cardiac arrest patients found in asystole or pulseless electrical activity. Resuscitation 2010, 81:679-684.
• [14]Jacobs I, Nadkami V, Bahr J, Berg RA, Billi JE, Bossaert L, Cassan P, Coovadia A, D'Este K, Finn J, Halperin H, Handley A, Herlitz J, Hickey R, Idris A, Kloeck W, Larkin GL, Mancini ME, Mason P, Mears G, Monsieurs K, Montgomery W, Morley P, Nichol G, Nolan J, Okada K, Perlman J, Shuster M, Steen PA, Sterz F, Tibballs J, Timerman S, Truitt T, Zideman D: Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa). Circulation 2004, 110:3385-3397.
• [15]Hess EP, Brison RJ, Perry JJ, Calder LA, Thiruganasambandamoorthy V, Agarwal D, Sadosty AT, Silvilotti MLA, Jaffe AS, Montori VM, Wells GA, Stiell IG: Development of a clinical prediction rule for 30-day cardiac events in emergency department patients with chest pain and possible acute coronary syndrome. Ann Emerg Med 2012, 59:115-125.
• [16]Abe T, Tokuda Y, Cook EF: Time-based partitioning model for predicting neurologically favorable outcome among adults with witnessed bystander out-of-hospital CPA. PLoS ONE 2011, 6:e28581.
• [17]Shewry MC, Wynn HP: Maxmum entropy sampling. J Appl Stat 1987, 14:165-170.
• [18]SAS: Modeling and multivariate methods. Recursive partition data. [http://www.jmp.com/support/help/Recursively_Partitioning_Data.shtml] webcite
• [19]Kagawa E, Dote K, Kato M, Sasaki S, Nakano Y, Kajikawa M, Higashi A, Itakura K, Sera A, Inoue I, Kawagoe T, Ishhara M, Shimatani Y, Kurisu S: Should we emergency revascularize occluded coronaries for cardiac arrest? Rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention. Circulation 2012, 126:1605-1613.
• [20]Holzer M: Targeted temperature management for comatose survivors of cardiac arrest. N Engl J Med 2010, 363:1256-1264.
• [21]Hazinski MF, Nolan JP, Nadkarni VM, Koster RW, Montgomery WH, Lim SH, Mancini ME, Zideman DA, Morley PT, Hickey RW, Billi JE, Morrison LJ, Bossaert L, O'Connor RE, Bottiger BW, Okada K, de Caen AR, Perlman JM, Deakin CD, Sayre MR, Drajer S, Shuster M, Eigel B, Soar J, Jacobs I, Sunde K, Kleinman ME, Travers AH, Kloeck WGJ, Wyllie J: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2010, 122:S250-S605.
• [22]Japan Resuscitation Council: 2010 Japanese Guideline for Emergency Care and Cardiopulmonary Resuscitation. Tokyo: Health shuppansha; 2011.
• [23]Skrifvars MB, Pettila V, Rosenberg OH, Castrén M: A multiple logistic regression analysis of in-hospital factors related to survival at six months in patients resuscitated from out-of-hospital ventricular fibrillation. Resuscitation 2003, 59:319-328.
• [24]Fonarow GC, Adams KF, Abraham WT, Yancy CW, Boscardin WJ, for the ADHERE Scientific Advisory Committee, Study Group, and Investigators: Risk stratification for in-hospital mortality in acute decompensated heart failure: classification and regression tree analysis. JAMA 2005, 293:572-580.
• [25]Carron PN, Taffe P, Hugli O: Use of epinephrine for cardiac arrest prior to hospital arrival. JAMA 2012, 308:29-30. [author reply, 30]
• [26]Lamborn KR, Chang SM, Prados MD: Prognostic factors for survival of patients with glioblastoma: recursive partitioning analysis. Neuro-Oncology 2004, 6:227-235.
• [27]Tokuda Y, Miyasato H, Stein GH: A simple prediction algorithm for bacteraemia in patients with acute febrile illness. Q J Med 2005, 98:813-820.
• [28]Hypothermia after Cardiac Arrest Study Group: Mild therapeutic hypothermia to improve neurological outcome after cardiac arrest. N Engl J Med 2002, 346:549-556.
• [29]Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K: Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002, 346:557-563.
• [30]Chen YS, Lin JW, Yu HY, Ko WJ, Jerng JS, Chan WT, Chen WJ, Huang SC, Chi NH, Wang CH, Chen LC, Tsai PR, Wang SS, Hwang JJ, Lin FY: Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet 2008, 372:554-561.
• [31]Neumar RW, Noal JP, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth JWT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoeket TV: Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication; a consensus statement from the International Liaison Committee on Resuscitation. Circulation 2008, 118:2452-2483.
• [32]Oddo M, Rosentti AO: Predicting neurological outcome after cardiac arrest. Curr Opin Crit Care 2011, 17:254-259.
• [33]Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S: Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA 2012, 307:1161-1168.
• [34]Nagao T, Kinoshita K, Sakurai A, Yamaguchi J, Furukawa M, Utagawa A, Moriya T, Azuhata T, Tanjoh K: Effects of bag-mask versus advanced airway ventilation for patients undergoing prolonged cardiopulmonary resuscitation in pre-hospital setting. J Emerg Med 2012, 42:162-170.
• [35]Japanese Guideline for Emergency Care and Cardiopulmonary Resuscitation. 3rd edition. Tokyo: Health shupansha; 2007.
• [36]American Heart Association: Guideline for cardiopulmonary resuscitation emergency cardiovascular care. Circulation 2000, 102:I1-384.
• [37]American Heart Association: Guideline for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2005, 112:IV1-203.