Independent evaluation of an out-of-hospital termination of resuscitation (TOR) clinical decision rule.

TitleIndependent evaluation of an out-of-hospital termination of resuscitation (TOR) clinical decision rule.
Publication TypeJournal Article
Year of Publication2008
AuthorsRichman PB, Vadeboncoeur TF, Chikani V, Clark L, Bobrow BJ
JournalAcad Emerg Med
Date Published2008 Jun
ISSN Number1553-2712
KeywordsArizona, Cardiopulmonary Resuscitation, Confidence Intervals, Decision Support Techniques, Emergency Medical Services, Female, Heart Arrest, Humans, Male, Medical Futility, Middle Aged, Practice Guidelines as Topic, Resuscitation Orders, Retrospective Studies, Survival Analysis, Withholding Treatment

OBJECTIVES: Recently, investigators described a clinical decision rule for termination of resuscitation (TOR) designed to help determine whether to terminate emergency medical services (EMS) resuscitative efforts for out-of-hospital cardiac arrests (OOHCA). The authors sought to evaluate the hypothesis that TOR would predict no survival for patients in an independent cohort of patients with OOHCA.

METHODS: This was a retrospective cohort analysis conducted in the state of Arizona. Consecutive, adult, OOHCA were prospectively evaluated from October 2004 through October 2006. A statewide OOHCA database utilizing Utstein-style reporting from 30 different EMS systems was used. Data were abstracted from EMS first care reports and hospital discharge records. The TOR guidelines predict that no survival to hospital discharge will occur if 1) an OOHCA victim does not have return of spontaneous circulation (ROSC), 2) no shocks are administered, and 3) the arrest is not witnessed by EMS personnel. Data were entered into a structured database. Continuous data are presented as means (+/-standard deviations [SD]) and categorical data as frequency of occurrence, and 95% confidence intervals (CIs) were calculated as appropriate. The primary outcome measure was to determine if any cohort member who met TOR criteria survived to hospital discharge.

RESULTS: There were 2,239 eligible patients; the study group included 2,180 (97.4%) patients for whom the data were complete; mean age was 64 (+/-11) years, and 35% were female. The majority of patients in the study group met at least one or more of the TOR criteria. A total of 2,047 (93.8%) patients suffered from cardiac arrest that was unwitnessed by EMS; 1,653 (75.8%) had an unwitnessed arrest and no ROSC. With respect to TOR, 1,160 of 2,180 (53.2%) patients met all three criteria; only one (0.09%; 95% CI = 0% to 0.5%) survived to hospital discharge.

CONCLUSIONS: The authors evaluated TOR guidelines in an independent, statewide OOHCA database. The results are consistent with the findings of the TOR investigation and suggest that this algorithm is a promising tool for TOR decision-making in the field.

Alternate JournalAcad Emerg Med
PubMed ID18616436
Faculty Reference: 
Bentley J. Bobrow, MD, FACEP, FAHA