When someone who has been resuscitated by paramedics after cardiac arrest comes into an emergency department, healthcare employees move quickly. If the patient remains unconscious, team members typically cool the patient’s body rapidly by using either ice packs or a device that cools the blood stream.
Cooling slows the release of damaging elements into the brain that build up in the blood following cardiac arrest. The process has been shown to protect the brain from further harm and to enhance recovery. The practice is a standard of care in emergency medicine. But a question has lingered: How long should the patient be cooled to maximize protection of the brain?
The search for an answer has become a pathway for Adventist Health Portland and Oregon Health & Science University, which integrated clinical services in 2018 through the OHSU Health system, to demonstrate their partnership’s value to patients across the city and beyond.
The Influence of Cooling Duration on Efficacy in Cardiac Arrest Patients clinical trial, also known as the ICECAP trial, aims to improve outcomes for patients who have a cardiac arrest before they arrive at an emergency department. The trial is part of the Strategies to Innovate Emergency Care Clinical Trials Network, or SIREN, of which OHSU is a hub.
Mohamud Daya, M.D., M.S., OHSU’s principal investigator for the SIREN network trials, had rotations at Adventist as an emergency medicine resident in the 1980s and knew the Adventist Emergency Department treated a relatively high number of patients in cardiac arrest.
Located along the I-205 corridor, Adventist serves the expansive neighborhoods of outer east Portland, which is home to thousands of residents who have either established roots there over generations, or have moved – or been displaced –because of how affordability, range and availability of housing there compares to neighborhoods that are closer to downtown. Income and education levels are lower than other parts of town and fresh food and recreation are harder to come by, all of which can affect health. (See sources below.)
“We knew that Adventist serves an area with a lot of people with risk factors for cardiac arrest,” said Daya, a professor of emergency medicine in the OHSU School of Medicine. “Adventist also does intravascular cooling. So they had the systems in place to get this clinical trial done.”
Adventist has enrolled 17 patients since it became part of the trial nine months ago. It's among the top three institutions in the number of participants enrolled among the trial’s 50 sites nationwide. “We see more patients in cardiac arrest come through our doors than the next two geographically closest hospitals to us combined – as many as 150 patients a year,” said Wes Rippey, M.D., chief medical officer for Adventist Health Portland who is also a general and peripheral vascular surgeon. “The trial seemed like a natural fit to look at what could be the best processes for care and how could we do that better. We want our patients to have the best possible chance at full recovery.”
Rippey credited the multidisciplinary team’s success in the trial to their organization and dedication. OHSU emergency medicine physicians teamed up with Adventist nurses and other healthcare team members to run the emergency department about three years ago as part of OHSU Health.
When cardiac arrest patients arrive at the Adventist Emergency Department, the healthcare team is ready to help. Once a patient is resuscitated, the team quickly surrounds the patient with ice while connecting them to an “Icy Cath,” a large catheter inserted into a vein in the groin attached to a machine that cools the blood.
Then a study coordinator or emergency physician sits down with the patient’s family and explains the opportunity for their loved one to be part of the clinical trial.
“We have very committed staff, providers, healthcare team members and ancillary departments who make sure we have the processes in place to deliver,” Rippey said. “OHSU’s emergency department providers are energetic. Our hospitalist group is similarly eager to produce results, as are our critical care and cardiology teams. With our mission to inspire health, wholeness and hope, we take time to explain things to families.”
Not every patient in cardiac arrest is right for the trial, or the trial may not be right for them. But all patients benefit.
“The high-quality care we have incorporated goes for all patients, not just those in the trial,” said Matthew Neth, M.D., an assistant professor of emergency medicine in OHSU School of Medicine, and the ICECAP lead investigator at Adventist for OHSU Health.
William Spurlock, D.O., an Adventist hospitalist, agreed.
“While we have always prided ourselves on our care of critically ill patients, the study has resulted in a new focus for everyone,” Spurlock said. “All of the providers are on the same page, from the physicians and nurses in the ER, to the physicians and nurses in the ICU. The study has improved our cohesiveness from that transition from the ER to the ICU. When we hear in the ICU that a cardiac arrest patient has arrived in the ER, the ICU team is already mobilizing to assist the ER.”
OHSU has always aimed to serve the public good, but its location on a hillside above downtown can mean it’s not ideally situated for everyone. As a community hospital, Adventist is closer to many patients. While Adventist didn’t have all of the infrastructure, data collection and analysis capabilities needed to support this study, OHSU did. Adventist has participated in cardiac research in the past, but Rippey said Adventist hasn’t done cardiac research at this level before.
The symbiosis hit a sweet spot for both institutions.
“OHSU and Adventist have that larger commitment to serving communities with the least access to opportunities,” said Anthony Ferroggiaro, M.D., an assistant professor of emergency medicine in the OHSU School of Medicine and the vice chair and medical director of the Adventist Emergency Department. “Looking at the challenges that communities on the east side are facing, improving those outcomes was a real driver for both institutions.”
Mary Tanski, M.D., M.B.A., who is an associate professor in the OHSU School of Medicine and will become permanent chair of OHSU emergency medicine July 1, said the trial illustrates the larger goals of the OHSU Health system.
“My goal for the OHSU emergency department system is to build and expand all three missions – clinical, research and teaching – with our community partners,” Tanski said. “Essentially, we are creating a hybrid community/academic emergency medicine model that is really attractive for emergency medicine physicians who want to practice clinical emergency medicine, interact with and teach residents and continue to explore and develop their research interests.”
Adventist’s Spurlock described the experience as “truly eye-opening.”
“My training and clinical work have not been at large academic centers, and I have never participated in a large study such as ICECAP before,” he said. “I’m proud of our team at Adventist for quickly embracing our participation in this study. I am hopeful and confident this study will be the first of many, in which our Portland Adventist site participates as part of the OHSU health system.”
CJ Anderson contributed to this report.