Although I am not taking care of cardiac patients but I do believe the existence of CAC is important for countries like USA and Canada where cardiac specialsits are most of time are hundreds of miles away. Centralized special centers are needed just like ECMO or trauma centers. However, in small countries where doctors sometimes are within walking distance or level III centers are within 30 minutes for the general population a CAC may not be beneficial. Also need to consider the fiscal burden to have a specialized center which may sometimes increase the cost so as to maintain a lot of specialized facilities and doctors. Every single life deserves to be saved but a bankrupt system will definitely not helping in the long run.

The question raises if CAC are preferable above "normal hospitals". This question depends fully of your country, the distances between centers with TCI (transcutaneous cardiac intervention) facilities, the level of care provided by the prehospital (H)EMS services and more.

Therefore Europe cannot be compared with the USA: the distances in western Europe are normaly shorter and the patient with an cardiac arrest can be brought to the nearest hospital in relative short time. Diagnosis (for interventinable) opportunities can than be bade in that hospital, whereafter secundary transport to a TCI facility can be made. Of course this transport can be as high equiped as you want: inclusive ECMO or IABP.

In my opinion not all the hospitals have to have TCI facility (to get the higher experience in the centres). this in fact is the situation in the Netherlands: an OHCA will be rescucitated by the EMS, and if ROSC, than transported to the regional TCI centre. If this takes to long the patinet can be primarily transported tot the nearest hospital. In case there is no ROSC, the EMS nurses are allowed to finish rescusitation after performing a number of shock or non-shock circles, as described in the national protocol for the ambulances.

In our EMS System we organized a direct transfer for victims with/without ROSC after OHCA direct to the PCI. In one investigation we found a 5fold higher survival in hospitals that act like a PRC.

I am not sure what a CAC would offer that a typical tertiary facility with an ICU, CCU and Cardiac Cath lab, and access to appropriate neurology expertise (Eg Brain Injury Rehab Unit- BIRU) doesn't already offer.

In Australia, metropoliatan areas are well served by such facilities. Where access to a tertiary facility is difficult eg rural locations, off mainland locations etc I think a CAC is unlikely to be a viable solution - throughput is unlikely to justify the expense involved and costs would be prohibitive.

I would like to know how many patients p.a CACs typically treat, and how they stand up to quantitative cost/benefit evaluation.

Perhaps up-skilling staff in critical care areas would be a more viable option?

Here in Perú don´t know about CAC. We have many limitations for attention of out hospital cardiac arrest . Here that patients are helped by the parents, firemen or, only in some places, by SAMU (Sistema de Atención Móvil de Urgencias), and then transfered to hospital (secondary or terciary level) that in the city are within 10 or 20 minutes for the population. I think that the CAC is very good strategy in populations with high prevalence of OHCA. In our country we need improve health system first.

This depends a little on the local medical environment and probably varies by country. In terms of medical capability most of the interventions post cardiac arrest that you need immediately are very low tech. Implementation of the cerebral protection hypothermia protocol requires nothing more than a cooling blanket, perhaps some refrigarator cooled saline. Hemodynamics are easily managed with pressors/ fluids. In the United States these are readily available in most hospitals. Certainly the inital treatment can be accomplished by almost any ER and trained ER doctor.

What may not be available is a cardiac cath lab for stent placement in case of acute MI, and inhouse physician availabilty 24/7 for post arrest critical care management. Ideally a patient should be taken to a hospital that has these capabilities. In locals that do not have these capabilities at least in the US the best approach would be to make sure all hospitals have the capability to 1) cool 2) stabilize hemodynamically 3) either provide the capability for acute cardiac intervention if indicated or have a pathway that is easily initiated to transfer to center that has this capability. I would recall that often patients with a cardiac arrest at home have an arrest as a result of underlying progressive chronic disease ( malignancies, advanced LV dysfunction, COPD, etc.. to transport all such patients to "cardiac arrest" centers is not likely to convey benefit

Severe brain injury is a heterogeneous disease with respect to cause, pathology, severity, and prognosis causing considerable uncertainty regarding outcome. Predicting recovery early in surviving comatose patients with various levels of consciousness is the cornerstone for individualized intensive care and can be addressed best in the setting of specialized care centers. Cardiac arrest (CA) is one of the main causes of severe brain injury, usually accompanied by impaired vital functions with high morbidity and mortality. Despite advances in cardiopulmonary resuscitation and post-CA care, mortality is still high with less than 30% of patients surviving until hospital discharge. The first half-year health care costs of out-of-hospital CA survivors are estimated at approximately 29’000 € in a study from the Netherlands.

Special care centers are important to address the complexity of the clinical and pathophysiological aspects of anoxic brain injury. Improvement in neurointensive care has led to an increasing proportion of surviving severely anoxic brain injured patients. Mild therapeutic hypothermia reduces neurologic injury and is a crucial integral component of post-CA care. It reduces mortality and improves functional outcome.

We have a fuctional CAC , a multi-disciplinary group of emergency nurses and physicians, cardiologists and intensive care physicians, which can providing excellence in care to post-cardiac arrest patients.

Our recent data are in Journal Article: Impact of Emergency Coronary Angiography on In-Hospital Outcome of Unconscious Survivors After Out-of-Hospital Cardiac Arrest. The American journal of cardiology. 09/2012.

I think that hypotermia, cath lab, Intensive care should be standard of care in these centers.

Dear Anthny, we have an ongoing study (doctoral dissertation) just on the outcome of neurological successfully resuscitated after cardiac arrest. The first results seem very encouraging being very high risk of brain damage from prolonged anoxia.

I think that Kai Robinson has it right when he suggests that the important aspect is 'developing a small team with specific therapeutic guiding principles'. Trauma centres are essentially large tertiary hospitals which are not necessarily different from others of the same size, but have a co-ordinated team approach which is designed around interdisciplinary collaboration and access to appropriate interventions at the same time. As in any part of the health system wherever it is, having the infrastructure isoften perceived (especially by politicians) as the complete solution, whereas those of us who work in the system realise that it is how it is used that is the real key. Process, instead of just structure, is far more related to outcomes; just ask Donabedian.

What is also important for cardiac arrest though is the absolute need for the 'system' to involve the community, the public and other aspects of health care. No ambulance service in the world can get to a patient who has had a cardiac arrest in the 3-4 minutes necessary to prevent death or hypoxic brain damage, and so we need to also concentrate on public health interventions such as community-wide CPR training, AED placement, AED registers, and cardiac arrest registries. Cardiac arrest centres and tinkering with EMS to allow direct transport to them may be the answer as far as the second part of the system is concerned, but they are almost pointless without the first part.

We are having this debate in NSW at the moment, as we have just published data showing that cardiac arrest outcomes appear to actually be getting worse.

Have a look at...

http://www.smh.com.au/national/health/warning-over-rise-in-heart-attack-deaths-outside-hospitals-20130924-2uc8w.html

and

http://www.smh.com.au/comment/change-of-heart-vital-to-stopping-needless-cardiac-arrest-deaths-20130924-2uc1t.html

The isssue is indeed, processes of care, as Dr. Middleton states. Both out and in-hospital care. You can have a tertiary center with cath lab and well trained healthcare providers, but it takes coordination to pull it off. Early recognition of cardiac arrest and good quality CPR is the key for better overall outcomes, but in-hospital recognition of when hypothermia needs to be initiated, leads to implementation of its measures and outcomes are better (overall) .

Let's look at the sepsis model and bundling of interventions - the more interventions in the bundle you do, the better the outcomes. No one knows exactly why, but it probably has to do with earlier recognition and doing all the right things.

Let's look at the literature in stroke outcomes. The quicker you intervene (through process improvement) - meaning tPA, endovascular intervention, etc) the better the outcomes are. The idea of CAC is that not only that you have available resources to care for this patients, but you actually deliver and constantly look for way to improve your delivery of "best practices".

Here is what Dr. Atte Meretoja has to say about stroke and door-to-needle tPA time: http://nyneurosymposium.columbia.edu/symposium/2013/Thursday/1110AM_Attaining_In-Hospital_Stroke_Thrombolysis_within_20_Minutes.pdf

It makes for a fascinating read on how can you improve in any process.

Regarding the number of fa(s)t food franchises/ sq mile, I have no idea whether is or not correlating, but I suspect it is. One should not however, directly associate that with cause and effect. McDonald's is an exceptionally well run company in which the decision to add a restaurant is incredibly well researched. There's a joke saying McDonalds is so good at finding new business, that Burger King opens a restaurant in an area only after McDonalds does. Who goes to these restaurants regularly? Usually people in the lower socio-economic status, more obese, and less likely to have access to preventive care. The Lower the socio-economic status is probably associated with more Fa(s)t Food restaurants.