While the clinical effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) has gained increasing attention, its real-world utilization, patient selection, and system-level implementation remain incompletely understood.

We conducted a descriptive cross-sectional analysis with time-series components using nationwide emergency department (ED) data from Korea between 2016 and 2023. ECPR cases were identified using diagnostic and procedural codes. Patient demographics, comorbidities, in-hospital procedures, and survival outcomes were compared with ECPR and conventional CPR (CCPR) recipients. Annual trends in ECPR frequency, proportion, and survival were assessed. Hospitals were categorized into core, sustained, intermittent, and one-time groups based on ECPR case volume and consistency over time.

Among 104,818 OHCA patients who received CPR, 724 (0.69%) underwent ECPR. ECPR recipients were younger (median age, 59 vs. 73 years) and had fewer comorbidities than CCPR recipients. The number of ECPR cases increased from 52 in 2016 to 111 in 2023, although its proportion plateaued at approximately 0.7% annually. Crude survival to hospital discharge was higher among ECPR recipients (26.9%) than CCPR recipients (13.5%), although no significant survival trend was observed. ECPR was predominantly performed at higher-level EDs (53.2%) and was highly concentrated: only 16 hospitals met the criteria for core centers, and most hospitals performed fewer than five cases annually. Core centers were geographically clustered, with several regions lacking access to any such facility.

In Korea, the annual number of ECPR cases for OHCA has increased, but its application remains selective and concentrated in a limited number of institutions. These findings highlight system-level variation in implementation and suggest the need for strategies to improve equity, coordination, and procedural quality in ECPR delivery.