Emergency medical service
Original research
Comparison of Termination-of-Resuscitation Guidelines for Basic Life Support: Defibrillator Providers in Out-of-Hospital Cardiac Arrest

https://doi.org/10.1016/j.annemergmed.2005.05.012Get rights and content

Study objective

Termination of resuscitation in the field for out-of-hospital cardiac arrest can reduce unnecessary transport to hospital and associated road hazards and increase availability of emergency medical services (EMS) and emergency department resources for other patients. We compare the performance of 3 termination-of-resuscitation guidelines for basic life support–defibrillator (BLS) providers when applied to cardiac arrest patients in the Ontario Prehospital Advanced Life Support study.

Methods

This prospective cohort study involved all out-of-hospital cardiac arrest patients attended by BLS defibrillator providers in 21 Ontario urban or suburban communities. The data analyses were conducted secondarily on these prospectively collected data. Three termination-of-resuscitation guidelines (referred to as Marsden, Petrie, and Verbeek rules) were applied and contingency tables calculated to show the relationship between the rule and actual survival.

Results

From 1988 to 2003, 13,684 cardiac arrest patients were attended by BLS defibrillator providers. Six hundred thirty-six (4.7%) patients survived to hospital discharge. For the 3 termination-of-resuscitation rules, sensitivity was 99.8% (95% confidence interval [CI] 99.5% to 100.0%) (Petrie rules), 99.5% (95% CI 99.0% to 100.0%) (Verbeek rules), and 99.8% (95% CI 99.5% to 100.0%) (Marsden rules). Specificity was 9.9% (95% CI 9.4% to 10.4%) (Petrie rules), 52.9% (95% CI 52.1% to 53.8%) (Verbeek rules), and 19.4 % (95% CI 18.8% to 20.1%) (Marsden rules). Negative predictive value was 99.9% (95% CI 99.8% to 100.0%) (Petrie rules), 100.0% (95% CI 99.9% to 100.0%) (Verbeek rules), and 100.0% (95% CI 99.9% to 100.0%) (Marsden rules). These rules would have resulted in field termination of resuscitation in 9.4% (Petrie rules), 50.5% (Verbeek rules), and 18.5 % (Marsden rules) of cases. Termination of resuscitation was recommended for 1 patient (Petrie rules), 3 patients (Verbeek rules), and 1 patient (Marsden rules), who survived.

Conclusion

We found all 3 termination-of-resuscitation rules to have high sensitivity and negative predictive value. However, the specificity and transport rates varied greatly. The results of this study will be useful for EMS providers considering adoption of termination of resuscitation in BLS defibrillator systems for out-of-hospital cardiac arrest.

Introduction

Survival rates from out-of-hospital cardiac arrest are generally low.1 Traditionally, patients who failed to respond to out-of-hospital resuscitation would be transported to the emergency department (ED) for continued efforts.2 However, since the late 1970s, researchers reporting the futility of such efforts for certain subsets of out-of-hospital cardiac arrest have been advocating termination of resuscitation in the field by advanced life support (ALS) providers.2, 3, 4, 5, 6, 7 Such patients would have received full ALS in the field, including defibrillation, intubation, and intravenous drugs before termination of resuscitation.

However, in many emergency medical services (EMS) systems, out-of-hospital cardiac arrest is attended only by basic life support (BLS) providers or emergency medical technicians (EMTs). These providers are capable of performing cardiopulmonary resuscitation (CPR) but usually not intubation and cannot administer intravenous drugs. Many are also equipped with automated external defibrillators (BLS defibrillator or EMT defibrillator). Suggestions have been made that termination of resuscitation can be implemented for BLS defibrillator systems as well. Three such guidelines have been proposed by Marsden et al,8 Petrie,9 and Verbeek et al10 (Figure 1). To date, comparatively little research has been published about termination of resuscitation for BLS compared to ALS systems. We also note that in North America,11 the UK,8, 10, 12 and around the world, EMT defibrillators may make up the predominant responders in many EMS systems. In 1995, Marsden et al8 proposed a termination of resuscitation algorithm based on a review of 414 cardiac arrest patients. This algorithm contained a treatment sequence based on the presence or absence of a “shockable” rhythm (see Figure 1). In 2001, Petrie9 reviewed 9,899 cardiac arrest cases in a BLS defibrillator system and found that there were no survivors to discharge for patients presenting with asystole if the call-response interval exceeded 8 minutes. He proposed that such patients could be considered for termination of resuscitation. Similarly, in 2002, Verbeek et al10 reviewed 700 cases in an EMT defibrillator system and found return of spontaneous circulation, defibrillation, and arrest witnessed by EMS to have the strongest association with survival. These factors were incorporated into a termination of resuscitation rule.

Field termination of resuscitation can reduce unnecessary transport to the hospital, reducing associated road hazards13 and increasing availability of EMS and ED resources for other patients.14, 15 Transport and in-hospital ALS is also associated with considerable financial cost.14, 15, 16 On the other hand, the decision to terminate resuscitation efforts is fraught with ethical and legal considerations.17, 18, 19, 20 Thus, any guidelines for termination of resuscitation in the field must of necessity be highly reliable and accurate and thus legally defensible. This article aims to compare the performance of the 3 published guidelines for termination of resuscitation by BLS providers attending to out-of-hospital cardiac arrest, using the largest cohort of out-of-hospital cardiac arrest patients available: the Ontario Prehospital Advanced Life Support (OPALS) study.21, 22, 23, 24

Section snippets

Study Design

The methodology of the cardiac arrest portion of the OPALS study has been published.21, 22, 23, 24 It was a 3-phase, before-and-after, controlled clinical trial. This article represents a prospective cohort study involving all out-of-hospital cardiac arrest patients attended by EMT defibrillators during 3 phases of the study. We secondarily analyzed the cases in this database.

Setting

The OPALS study was conducted in 21 Ontario urban or suburban communities, which range in population from 16,000 to

Results

For 1988 to 2003, EMS attended to 21,913 cardiac arrest patients altogether. BLS defibrillator paramedics treated 13,684 consecutive eligible cardiac arrest patients, and none were lost to follow-up; 8,229 patients were attended by ALS paramedics during this period and were excluded. The patient and system characteristics are elaborated on in Table 1. Of eligible patients, 636 (4.7%) survived to hospital discharge. Information on initial rhythm was available for 13,148 cases.

Performance of the

Limitations

Several limitations of this study need to be mentioned. The termination of resuscitation guidelines proposed by Marsden et al8 are in the form of a time sequence algorithm, which is difficult to replicate retrospectively. Instead this has been simplified into decision rules for statistical analysis. For example, the rule “no evidence of CPR in the last 15 minutes” was operationalized into either having unwitnessed arrest with no bystander CPR or witnessed arrest with response time greater than

Discussion

We found all 3 termination-of-resuscitation rules to have high sensitivity (ability to predict survivors and recommend transport for all of them) and high negative predictive value (ensuring that as few patients as possible who have been pronounced dead in the field might actually have survived) (Table 2). However, the specificity and transport rates of the 3 rules varied greatly (Table 2).

According to the original reports by Marsden et al,8 Petrie,9 and Verbeek et al,10 these rules all had

References (32)

  • W.L. Hall et al.

    The perspective of paramedics about on-scene termination of resuscitation efforts for pediatric patients

    Resuscitation

    (2004)
  • M.J. Bonnin et al.

    Distinct criteria for termination of resuscitation in the out-of-hospital setting

    JAMA

    (1993)
  • P.G. Faine et al.

    Implementation of an out-of-hospital termination of resuscitation policy

    Prehosp Emerg Care

    (1997)
  • M.R. Streger et al.

    Cardiac care 2000field termination of cardiac arrest resuscitation

    Emerg Med Serv.

    (2000)
  • A.L. Kellermann et al.

    Predicting the outcome of unsuccessful prehospital advanced cardiac life support

    JAMA

    (1993)
  • A.K. Marsden et al.

    When is it futile for ambulance personnel to initiate cardiopulmonary resuscitation?

    BMJ

    (1995)
  • Cited by (60)

    • Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

      2020, Resuscitation
      Citation Excerpt :

      Reported sensitivities and specificities of included papers are listed in Table 2. We identified very low-certainty evidence (downgraded for risk of bias, inconsistency, indirectness, and imprecision) from 13 nonrandomized studies50,51,56,58,63–66,68,70–72,76 reporting the accuracy of the BLS TOR rule to predict in-hospital death. There was considerable heterogeneity across patient populations, clinician populations, and EMS systems; thus, meta-analysis was not appropriate.

    • Diagnostic performance of the basic and advanced life support termination of resuscitation rules: A systematic review and diagnostic meta-analysis

      2020, Resuscitation
      Citation Excerpt :

      Thus, data on BLS-treated patients for the BLS-rule and ALS-treated patients for the ALS-rule.17,18 Twelve of the included studies had a maximum QUADAS-2 score and thus a low risk of bias (Supplemental Table S1).6,7,12,13,17–20,36,37,39,40 Seven studies were at risk of bias in the domain “Flow and timing”, because not all patients were transported to the hospital (transport rate <100%).8,11,14,33–35,38

    • Evaluation of the Uptake of a Prehospital Cardiac Arrest Termination of Resuscitation Rule

      2020, Journal of Emergency Medicine
      Citation Excerpt :

      In the initial validation study, the BLS-TOR prediction rule was found to have an excellent positive predictive value for death (99.5%), a survival rate of 0.5% (95% confidence interval 0.1–0.9%), and would have reduced transport by 62.6% (3). Subsequent studies have found similar results (5–8). It should be noted that other regions use varying methods when determining the appropriateness of TOR.

    View all citing articles on Scopus

    Supervising editors: Donald M. Yealy, MD; Michael L. Callaham, MD

    Author contributions: MEHO and IS developed the conception of the study. MEHO and LN were responsible for data collection and management. MEHO and JJ were responsible for the data analysis. MEHO drafted the manuscript, and all contributed to the final manuscript. All authors have made substantive contributions to the study, and all authors endorse the data and conclusions. MEHO had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. MEHO takes responsibility for the paper as a whole.

    Funding and support: The authors report this study did not receive any outside funding or support.

    Reprints not available from the authors.

    View full text