Termination of resuscitation in the prehospital setting: A comparison of decisions in clinical practice vs. recommendations of a termination rule

Dominique V M Verhaert; Judith L Bonnes; Joris Nas; Wessel Keuper; Pierre M van Grunsven; Joep L R M Smeets; Menko Jan de Boer; Marc A Brouwer

doi:10.1016/j.resuscitation.2015.12.014

Termination of resuscitation in the prehospital setting: A comparison of decisions in clinical practice vs. recommendations of a termination rule

Resuscitation. 2016 Mar:100:60-5. doi: 10.1016/j.resuscitation.2015.12.014. Epub 2016 Jan 13.

Authors

Dominique V M Verhaert¹, Judith L Bonnes², Joris Nas¹, Wessel Keuper¹, Pierre M van Grunsven³, Joep L R M Smeets¹, Menko Jan de Boer¹, Marc A Brouwer¹

Affiliations

¹ Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.
² Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands. Electronic address: judithbonnes@gmail.com.
³ Regional Ambulance Service Gelderland-Zuid, Professor Bellefroidstraat 11, 6525 AG Nijmegen, The Netherlands.

PMID: 26774173
DOI: 10.1016/j.resuscitation.2015.12.014

Abstract

Background: Of the proposed algorithms that provide guidance for in-field termination of resuscitation (TOR) decisions, the guidelines for cardiopulmonary resuscitation (CPR) refer to the basic and advanced life support (ALS)-TOR rules. To assess the potential consequences of implementation of the ALS-TOR rule, we performed a case-by-case evaluation of our in-field termination decisions and assessed the corresponding recommendations of the ALS-TOR rule.

Methods: Cohort of non-traumatic out-of-hospital cardiac arrest (OHCA)-patients who were resuscitated by the ALS-practising emergency medical service (EMS) in the Nijmegen area (2008-2011). The ALS-TOR rule recommends termination in case all following criteria are met: unwitnessed arrest, no bystander CPR, no shock delivery, no return of spontaneous circulation (ROSC).

Results: Of the 598 cases reviewed, resuscitative efforts were terminated in the field in 46% and 15% survived to discharge. The ALS-TOR rule would have recommended in-field termination in only 6% of patients, due to high percentages of witnessed arrests (73%) and bystander CPR (54%). In current practice, absence of ROSC was the most important determinant of termination [aOR 35.6 (95% CI 18.3-69.3)]. Weaker associations were found for: unwitnessed and non-public arrests, non-shockable initial rhythms and longer EMS-response times.

Conclusion: While designed to optimise hospital transportations, application of the ALS-TOR rule would almost double our hospital transportation rate to over 90% of OHCA-cases due to the favourable arrest circumstances in our region. Prior to implementation of the ALS-TOR rule, local evaluation of the potential consequences for the efficiency of triage is to be recommended and initiatives to improve field-triage for ALS-based EMS-systems are eagerly awaited.

Keywords: Clinical practice; Guidelines; Out-of-hospital cardiac arrest; Resuscitation orders; Termination of resuscitation.

Publication types

Comparative Study
Observational Study

MeSH terms

Aged
Cardiopulmonary Resuscitation / methods
Cardiopulmonary Resuscitation / statistics & numerical data*
Decision Support Techniques
Emergency Medical Services
Female
Guidelines as Topic
Humans
Male
Medical Futility*
Middle Aged
Netherlands
Out-of-Hospital Cardiac Arrest / therapy*
Registries
Resuscitation Orders*
Retrospective Studies