Extracorporeal cardiopulmonary resuscitation (ECPR) may improve outcomes in selected patients with refractory out-of-hospital cardiac arrest (OHCA), but timely access is essential. In Greater London, a prehospital ECPR pathway enables transport of eligible patients to extracorporeal membrane oxygenation (ECMO)-capable centres within a target arrest-to-arrival interval of 45 min. We quantified accessibility to this pathway and explored how alternative service configurations might influence access.

This retrospective, observational study analysed five years of routinely collected OHCA data from the London Ambulance Service to identify patients meeting the ECPR eligibility criteria. Using pathway modelling and geospatial analysis we estimated the proportion of patients able to reach an ECMO-capable centre within 45 min and evaluated potential strategies for improving access.

776 patients were identified as being eligible for the prehospital ECPR pathway, but only 3% (n = 23/776) were estimated to reach an ECMO-capable centre during operating hours and within 45 min of cardiac arrest. In many cases, the threshold was exceeded before patients were ready for transport. Extending the arrest-to-arrival interval to 60 min resulted in a 217% increase (50 additional patients) predicted to access the pathway. Other improvements included extending operating hours (+104%, n = 24), broadening pathway activation criteria (+52%, n = 12), and increasing the number of receiving centres (+30%, n = 7).

Accessibility to the prehospital ECPR pathway appears limited. Modifications to operational parameters, particularly extending time thresholds and operating hours, could substantially increase access. These findings have important implications for the design and optimisation of ECPR services in urban medical systems.