title: Implementation of the fifth link of the chain of survival concept for out-of-hospital cardiac arrest.
abstract: BACKGROUND
  The American Heart Association 2010 resuscitation guidelines recommended adding a fifth link (multidisciplinary postresuscitation care in a regional center) to the previous 4 in the chain of survival concept for out-of-hospital cardiac arrest. Our study aimed to determine the effectiveness of this fifth link.
  
  
  RESULTS
  This multicenter prospective cohort study involved all eligible out-of-hospital cardiac arrest patients in the Aizu region (n=1482, suburban/rural, Fukushima, Japan). Proportions of favorable neurological outcomes were evaluated before (January 2006-April 2008) and after (January 2009-December 2010) the implementation of the fifth link. After implementation, all patients were transported directly from the field to the tertiary-level hospital or secondarily from an outlying hospital to the tertiary-level hospital after restoration of circulation. The tertiary hospital provided intensive postresuscitation care, including appropriate hemodynamic and respiratory management, therapeutic hypothermia, and percutaneous coronary intervention. One-month survival with a favorable neurological outcome among all patients treated by emergency medical services providers improved significantly after implementation (4 of 770 [0.5%] versus 21 of 712 [3.0%]; P<0.001). The adjusted odds ratios of favorable neurological outcome were 0.9 (95% confidence interval, 0.7-1.1) for early access to emergency medical care, 3.1 (95% confidence interval, 0.7-14.2) for bystander resuscitation, 14.7 (95% confidence interval, 3.2-67.0) for early defibrillation, 1.0 (95% confidence interval, 1.0-1.1) for early advanced life support, and 7.8 (95% confidence interval, 1.6-39.0) for the fifth link.
  
  
  CONCLUSIONS
  The proportion of out-of-hospital cardiac arrest patients with a favorable neurological outcome improved significantly after the implementation of the fifth link, which may be an independent predictor of outcome.
  
  
  BACKGROUND
  URL: http://www.apps.who.int/trialsearch. Unique identifier: UMIN000001607.
authors: Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan. t-tagami@nms.ac.jp
authors: Takashi
authors: T
authors: Tagami
authors: Kazuhiko
authors: K
authors: Hirata
authors: Toshiyuki
authors: T
authors: Takeshige
authors: Junichiroh
authors: J
authors: Matsui
authors: Makoto
authors: M
authors: Takinami
authors: Masataka
authors: M
authors: Satake
authors: Shuichi
authors: S
authors: Satake
authors: Tokuo
authors: T
authors: Yui
authors: Kunihiro
authors: K
authors: Itabashi
authors: Toshio
authors: T
authors: Sakata
authors: Ryoichi
authors: R
authors: Tosa
authors: Shigeki
authors: S
authors: Kushimoto
authors: Hiroyuki
authors: H
authors: Yokota
authors: Hisao
authors: H
authors: Hirama
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary; D016887:Cardiopulmonary Resuscitation; D015331:Cohort Studies; D005260:Female; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D007036:Hypothermia, Induced; D015994:Incidence; D007564:Japan; D008297:Male; D008875:Middle Aged; D009422:Nervous System Diseases / Q000453:epidemiology; D058687:Out-of-Hospital Cardiac Arrest / Q000150:complications / Q000401:mortality* / Q000628:therapy*; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012119:Respiration; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome