Development and Validation of the Good Outcome Following Attempted Resuscitation (GO-FAR) Score to Predict Neurologically Intact Survival After In-Hospital Cardiopulmonary Resuscitation

Abstract

IMPORTANCE Informing patients and providers of the likelihood of survival after in-hospital cardiac arrest (IHCA), neurologically intact or with minimal deficits, may be useful when discussing do-not-attempt-resuscitation orders. OBJECTIVE To develop a simple prearrest point score that can identify patients unlikely to survive IHCA, neurologically intact or with minimal deficits. DESIGN, SETTING, AND PARTICIPANTS The study included 51 240 inpatients experiencing an index episode of IHCA between January 1, 2007, and December 31, 2009, in 366 hospitals participating in the Get With the Guidelines-Resuscitation registry. Dividing data into training (44.4%), test (22.2%), and validation (33.4%) data sets, we used multivariate methods to select the best independent predictors of good neurologic outcome, created a series of candidate decision models, and used the test data set to select the model that best classified patients as having a very low (<1%), low (1%-3%), average (>3%-15%), or higher than average (>15%) likelihood of survival after in-hospital cardiopulmonary resuscitation for IHCA with good neurologic status. The final model was evaluated using the validation data set. MAIN OUTCOMES AND MEASURES Survival to discharge after in-hospital cardiopulmonary resuscitation for IHCA with good neurologic status (neurologically intact or with minimal deficits) based on a Cerebral Performance Category score of 1. RESULTS The best performing model was a simple point score based on 13 prearrest variables. The C statistic was 0.78 when applied to the validation set. It identified the likelihood of a good outcome as very low in 9.4% of patients (good outcome in 0.9%), low in 18.9% (good outcome in 1.7%), average in 54.0% (good outcome in 9.4%), and above average in 17.7% (good outcome in 27.5%). Overall, the score can identify more than one-quarter of patients as having a low or very low likelihood of survival to discharge, neurologically intact or with minimal deficits after IHCA (good outcome in 1.4%). CONCLUSIONS AND RELEVANCE The Good Outcome Following Attempted Resuscitation (GO-FAR) scoring system identifies patients who are unlikely to benefit from a resuscitation attempt should they experience IHCA. This information can be used as part of a shared decision regarding do-not-attempt-resuscitation orders.

CEASE: A Guide for Clinicians on How to Stop Resuscitation Efforts

“…Finally, our obligation to family involves providing information and support during their time of loss. • Dependent for ADLs* 48 • Homebound* 11 • Living in SNF † 13 • Neurologic status † 13 • Altered mental status* 48 • Medical noncardiac diagnosis ‡ 13,48 • Pneumonia ‡ 11,13,48 • Hypotension* 11,48 • Renal insufficiency/failure ‡ 11,13,48 • Acute stroke † 13 • Septicemia † 13 • Respiratory insufficiency † 13 • Major trauma ‡ 13,48 • Witnessed arrest* 49 • *Associated with survival †Associated with neurological outcome ‡Associated with both survival and neurological outcome §Based on expert opinion, or data from laboratory or out of hospital arrest studies…”

“…11,12 Ebell et al developed a prediction model for neurologic outcome and found that good neurologic function on hospital admission is most highly associated with a good neurologic outcome after resuscitation (able to work with minimal impairment), while trauma, stroke and age 85 or older are associated with greater impairment. 13 In children, renal failure and epinephrine infusion prior to the arrest were associated with mortality. 14 Therefore knowing the patient's history is critical.…”

Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis

“…Using data from over 50,000 in-hospital cardiac arrests contained in the American Heart Association's 'Get with the Guidelines' registry project, Ebell et al 159 developed a scoring system to identify patients who were unlikely to benefit from a resuscitation attempt. The Good Outcome Following Attempted Resuscitation (GO-FAR) scoring system was able to identify a cohort of patients (approximately 10% of acute admissions) who had a very low chance of a good outcome (< 1% survival with intact brain function).…”

Postcardiac Arrest Management

“…[30][31][32][33][34][35] The authors prefer the Pittsburgh Post-Cardiac Arrest Category (PCAC), because it uses bedside assessment and testing on hospital arrival rather than historical variables, thus providing early outcome prediction and facilitating risk-adjusted decision-making for hospital-based procedures and interventions. The PCAC is a validated, early postcardiac arrest illness severity score based on initial cardiopulmonary dysfunction (Sequential Organ Failure Assessment [SOFA] score: cardiovascular and respiratory components) and neurologic examination (FOUR score: motor and brainstem components).…”