Field termination-of-resuscitation rule for refractory out-of-hospital cardiac arrests in Japan

Abstract

Background: Guidelines for cardiopulmonary resuscitation (CPR) recommend using the universal termination-of-resuscitation (TOR) rule to identify out-of-hospital cardiac arrest (OHCA) patients eligible for field termination of resuscitation, thus avoiding medically futile transportation to the hospital. However, in Japan, emergency medical services (EMS) personnel are forbidden from terminating CPR in the field and transport almost all patients with OHCA to hospitals. We aimed to develop and validate a novel TOR rule to identify patients eligible for field termination of CPR. Methods: We analyzed 540,478 patients with OHCA from 2011 to 2015 using a Japanese registry. Main outcome measures were specificity and positive predictive value (PPV) of the newly developed TOR rule in predicting 1-month mortality after OHCA. Results: Recursive partitioning analysis in the development group (n = 434,208) showed that EMS personnel could consider TOR if patients with OHCA met all of the following five criteria: (1) initial asystole, (2) arrest unwitnessed by a bystander, (3) age 81 years, (4) no bystander-administered CPR or automated external defibrillator use before EMS arrival, and (5) no return of spontaneous circulation after EMS-initiated CPR for 14 min. For patients meeting these criteria, specificity and PPV for predicting 1-month mortality were 99.2% [95% confidence interval (CI), 99.0-99.3%] and 99.7% (95% CI, 99.6-99.7%), respectively, for the development group and were 99.5% (95% CI, 99.3-99.7%) and 99.8% (95% CI, 99.7-99.9%), respectively, for the validation group. Implementation of this novel rule would reduce patient transports to hospitals by 10.6% in the development group and 10.4% in the validation group. Conclusions: Having both high specificity and PPV of >99% for predicting 1-month mortality, our developed TOR rule may be applied in the field for Japanese patients with OHCA who meet all five criteria. Prospective validation studies and establishment of prehospital EMS protocol are required before implementing this rule.

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

“…The lower specificity could hypothetically be driven by patients surviving with an impaired neurologic status. 49 However, as not all studies report on neurologic outcome, these results should be interpreted with caution and the exact cause of the lower specificity remains to be elucidated.…”

“…Previous studies showed that chances of falsely recommending TOR decrease with increasing time to TOR-assessment. 19,38,45 For example, patients without ROSC/defibrillation after 5 min have higher survival chances than after 20 min, and therefore early application of the rule may result in undesired termination-advice. Asian regions often apply a scoop-andrun strategy, with short in-field CPR-duration (2À4 min.…”

“…Previous Asian studies indeed showed that specificity decreased with decreasing time to TOR-rule application. 19,45 However, in absence of uniform reporting of these time intervals statistical analyses on this hypothesis were not feasible.…”

Education, Implementation, and Teams

“…Studies Reporting the Derivation and Internal Validation of a TOR Rule to Predict Poor Neurological Outcome. We identified very low-certainty evidence (downgraded for risk of bias, inconsistency, indirectness, and imprecision) from 6 nonrandomized studies 57,58,61,66,74,80 These studies derived and internally validated 12 distinct TOR rules to predict poor neurological outcome. Studies by Haukoos et al, 61 Lee et al, 66 Shibahashi et al, 74 and Yoon et al 80 derived multiple TOR rules.…”

Public location and survival from out-of-hospital cardiac arrest in the public-access defibrillation era in Japan

“…Cardiac arrest treatments are based on the Japanese CPR guidelines [5]. Most patients in OHCA are treated by EMS personnel, transported to a hospital, and registered in the All-Japan Utstein registry [17], because EMS providers are not basically permitted to terminate resuscitation in the field, except in cases involving victims of decapitation, incineration, decomposition, rigor mortis, or dependent cyanosis.…”