Predictive performance of universal termination of resuscitation rules in an Asian community: are they accurate enough?

Abstract

Introduction Prehospital termination of resuscitation (TOR) rules have not been widely validated outside of Western countries. This study evaluated the performance of TOR rules in an Asian metropolitan with a mixed-tier emergency medical service (EMS). Methods We analysed the Utstein registry of adult, non-traumatic out-of-hospital cardiac arrests (OHCAs) in Taipei to test the performance of TOR rules for advanced life support (ALS) or basic life support (BLS) providers. ALS and BLS-TOR rules were tested in OHCAs among three subgroups: (1) resuscitated by ALS, (2) by BLS and (3) by mixed ALS and BLS. Outcome definition was in-hospital death. Sensitivity, specificity, positive predictive value (PPV), negative predictive value and decreased transport rate (DTR) among various provider combinations were calculated. Results Of the 3489 OHCAs included, 240 were resuscitated by ALS, 1727 by BLS and 1522 by ALS and BLS. Overall survival to hospital discharge was 197 patients (5.6%). Specificity and PPV of ALS-TOR and BLS-TOR for identifying death ranged from 70.7% to 81.8% and 95.1% to 98.1%, respectively. Applying the TOR rules would have a DTR of 34.2–63.9%. BLS rules had better predictive accuracy and DTR than ALS rules among all subgroups. Conclusions Application of the ALS and BLS TOR rules would have decreased OHCA transported to the hospital, and BLS rules are reasonable as the universal criteria in a mixed-tier EMS. However, 1.9–4.9% of those who survived would be misclassified as non-survivors, raising concern of compromising patient safety for the implementation of the rules.

Beyond prognostication: ambulance personnel’s lived experiences of cardiac arrest decision-making

“…Termination of resuscitation guidelines has been developed, implemented and evaluated in ambulance services around the world,4–6 but there is a lack of international consensus6 and limited clinical compliance 7 8. Resuscitation consensus guidelines recommend a cautious approach regarding intra-arrest prognostication9 and withholding of resuscitation efforts 10…”

What should we consider when applying termination of resuscitation rules?

“…The TOR rule does not specify a time limit for EMS to declare "no ROSC" despite resuscitation attempts, and due to this vagueness, it should specify protocols, algorithms, and results for OHCA patients in accordance with local EMS systems (8,9,(17)(18)(19). The AHA guidelines made an addition of requiring 3 full rounds of CPR and automated external defibrillator analysis before EMS can declare "no ROSC" in the field (10).…”

Should we take patients to hospital in cardiac arrest?

“…8 BLS-TOR also performed poorly in a validation study in Taipei, incorrectly identifying 4.9% of 3489 patients who survived to hospital discharge as non-survivors. 9 A similar study in Singapore showed specificities ranging from 81% to 91% when applied retrospectively to 2269 cardiac arrests out of hospital. 10…”