Implementation trial of the basic life support termination of resuscitation rule: reducing the transport of futile out-of-hospital cardiac arrests.

BACKGROUND: The basic life support (BLS) termination of resuscitation (TOR) rule recommends transport and continued resuscitation when cardiac arrest is witnessed by EMT-Ds, or there is a return of spontaneous circulation, or a shock is given, and prior studies have suggested the transport rate should fall to 37%. METHODS AND RESULTS: This real-time prospective multi-center implementation trial evaluated the BLS TOR rule for compliance, transport rate and provider and physician comfort. Both provider and physician noted their decision-making rationale and ranked their comfort on a 5-point Likert scale. Functional survival was measured at discharge. Of 2421 cardiac arrests, 953 patients were eligible for the rule, which was applied correctly for 755 patients (79%) of which 388 were terminated. 565 patients were transported resulting in a reduction of the transport rate from 100% (historical control) to 59% (p<0.001). The BLS TOR rule was not followed in 198 eligible patients (21%) and they were all transported despite meeting the criteria to terminate. Providers cited 241 reasons for non-compliance: family distress, short transport time interval, younger age and public venue. All 198 transported patients, non-compliant with the rule, died. Both providers and physicians were comfortable with using the rule to guide TOR (median [IQR] of 5 [4,5]; p<0.001). CONCLUSIONS: This implementation trial confirmed the accuracy of the BLS TOR rule in identifying futile out-of-hospital cardiac arrest (OHCA) resuscitations, significantly reduced the transport rate of futile OHCA and most providers and physicians were comfortable following the rule's recommendations.

Adaptation and implementation of standardized order sets in a network of multi-hospital corporations in rural Ontario.

Standardized, preprinted or computer-generated physician orders are an attractive project for organizations that wish to improve the quality of patient care. The successful development and maintenance of order sets is a major undertaking. This article recounts the collaborative experience of the Grey Bruce Health Network in adapting and implementing an existing set of physician orders for use in its three hospital corporations. An Order Set Committee composed of primarily front-line staff was given authority over the order set development, approval and implementation processes. This arrangement bypassed the traditional approval process and facilitated the rapid implementation of a large number of order sets in a short time period.

Inter-rater reliability and comfort in the application of a basic life support termination of resuscitation clinical prediction rule for out of hospital cardiac arrest.

STUDY OBJECTIVE: This study evaluates inter-rater reliability and comfort of BLS providers with the application of an out-of-hospital Basic Life Support Termination of Resuscitation (BLS TOR) clinical prediction rule. This rule suggests that continued BLS cardiac resuscitation is futile and can be terminated in the field if the following three conditions are met: (1) no return of spontaneous circulation; (2) no shock given prior to transport; (3) cardiac arrest not witnessed by EMS personnel. METHODS: Providers hypothetically applied the rule and rated their comfort level on a five-point Likert-type scale, from "very comfortable" to "very uncomfortable" during the prospective validation of a BLS TOR clinical prediction rule in out-of-hospital cardiac arrest conducted in 12 rural and urban communities [Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. New Engl J Med 2006;355(5):478-87]. A Kappa score measured agreement between providers and compared to the correct interpretation of the rule. RESULTS: We compared mean comfort levels of providers who interpreted the rule correctly versus incorrectly. Of 1240 enrolled cases, 1184 (95.5%) had paramedic attendant forms and 1211 (97.7%) had driver forms and 1175 (94.7%) had both. Kappa for interpretation agreement between driver and attendant was 0.90 (95% CI, 0.87-0.92); between attendant and correct interpretation of the BLS TOR clinical prediction rule, 0.88 (95% CI, 0.85-0.91); between driver and correct interpretation of the BLS TOR clinical prediction rule, 0.88 (95% CI, 0.85-0.91). For instances in which both providers applied the rule correctly (607/635 [95.6%]), the providers were significantly more comfortable (chi(2)(4)=30.5, p<0.0001) than those instances in which they did not (28/635 [4.4%]. CONCLUSIONS: The vast majority of providers were able to apply the BLS TOR clinical prediction rule correctly and were comfortable doing so. This suggests that both reliability and comfort will remain high during routine application of the rule when paramedics are well trained as users of the rule.

Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest.

BACKGROUND: We prospectively evaluated a clinical prediction rule to be used by emergency medical technicians (EMTs) trained in the use of an automated external defibrillator for the termination of basic life support resuscitative efforts during out-of-hospital cardiac arrest. The rule recommends termination when there is no return of spontaneous circulation, no shocks are administered, and the arrest is not witnessed by emergency medical-services personnel. Otherwise, the rule recommends transportation to the hospital, in accordance with routine practice. METHODS: The study included 24 emergency medical systems in Ontario, Canada. All patients 18 years of age or older who had an arrest of presumed cardiac cause and who were treated by EMTs trained in the use of an automated external defibrillator were included. The patients were treated according to standard guidelines. Characteristics of diagnostic tests for the prediction rule were calculated. These characteristics include sensitivity, specificity, and positive and negative predictive values. RESULTS: Follow-up data were obtained for all 1240 patients. Of 776 patients with cardiac arrest for whom the rule recommended termination, 4 survived (0.5 percent). The rule had a specificity of 90.2 percent for recommending transport of survivors to the emergency department and had a positive predictive value for death of 99.5 percent when termination was recommended. Implementation of this rule would result in a decrease in the rate of transportation from 100 percent of patients to 37.4 percent. The addition of other criteria (a response interval greater than eight minutes or a cardiac arrest not witnessed by a bystander) would further improve both the specificity and positive predictive value of the rule but would result in the transportation of a larger proportion of patients. CONCLUSIONS: The use of a clinical prediction rule for the termination of resuscitation may help clinicians decide whether to terminate basic life support resuscitative efforts in patients having an out-of-hospital cardiac arrest.