Modification of termination of resuscitation rule with compression time interval in South Korea

Abstract

This study aimed to validate the predictive performance of the termination of resuscitation (TOR) rule and examine the compression time interval (CTI) as a criterion for modifying the rule. This retrospective observational study analyzed adult out-of-hospital cardiac arrest (OHCA) patients attended by emergency medical service (EMS) providers in mixed urban–rural areas in Korea in 2020 and 2021. We evaluated the predictive performance of basic life support (BLS) and the Korean Cardiac Arrest Research Consortium (KoCARC) TOR rule using the false-positive rate (FPR) and positive predictive value (PPV). We modified the age cutoff criterion and examined the CTI as a new criterion. According to the TOR rule, 1827 OHCA patients were classified into two groups. The predictive performance of the BLS TOR rule had an FPR of 11.7% (95% confidence interval (CI): 5.9–17.5) and PPV of 98.4% (97.6–99.2) for mortality, and an FPR of 3.6% (0.0–7.8) and PPV of 78.6% (75.9–81.3) for poor neurological outcomes at hospital discharge. The predictive performance of the KoCARC TOR rule had an FPR of 5.0% (1.1–8.9) and PPV of 98.9% (98.0–99.8) for mortality, and an FPR of 3.7% (0.0–7.8) and PPV of 50.0% (45.7–54.3) for poor neurological outcomes at hospital discharge. The modified cutoff value for age was 68 years, with an area under the receiver operating characteristic curve over 0.7. In the group that met the BLS TOR rule, the cutoff of the CTI for death was not determined and was 21 min for poor neurological outcomes. In the group that met the KoCARC TOR rule, the cutoff of the CTI for death and poor neurological outcomes at the time of hospital discharge was 25 min and 21 min, respectively. The BLS TOR and KoCARC TOR rules showed inappropriate predictive performance for mortality and poor neurological outcomes. However, the predictive performance of the TOR rule could be supplemented by modifying the age criterion and adding the CTI criterion of the KoCARC.

Termination of Resuscitation Rules and Survival Among Patients With Out-of-Hospital Cardiac Arrest

“…First-pass title and abstract screening yielded 131 potentially eligible studies. After the second-pass full-text screening, 43 studies remained (Figure 1).…”

“…When the BLS TOR rule is applied within systems deploying clinicians operating above the BLS level, it should be reported as the UTOR rule . Multiple studies reporting BLS TOR rule performance included responders who operated above the BLS level . However, clinicians providing BLS cannot administer adrenaline or undertake advanced airway interventions.…”

“…We identified very low-certainty evidence (downgraded for risk of bias, inconsistency, imprecision, indirectness, and publication bias) from 33 observational studies involving 927 534 cases. These studies reported external data validations of 17 TOR rules.…”

“…First-pass title and abstract screening yielded 131 potentially eligible studies. After the second-pass full-text screening, 43 studies 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 remained ( Figure 1 ).…”

“…54 Multiple studies reporting BLS TOR rule performance included responders who operated above the BLS level. 27,33,36,41,42,46,47,58,60,64,68 However, clinicians providing BLS cannot administer adrenaline or undertake advanced airway interventions.…”