Implementation of the ALERT algorithm,a new dispatcher-assisted telephone cardiopulmonary resuscitation protocol,in non-Advanced Medical Priority Dispatch System (AMPDS) Emergency Medical Services centres

Objectives

Early bystander cardiopulmonary resuscitation (CPR) is a key factor in improving survival from out-of-hospital cardiac arrest (OHCA). The ALERT (Algorithme Liégeois d’Encadrement à la Réanimation par Téléphone) algorithm has the potential to help bystanders initiate CPR. This study evaluates the effectiveness of the implementation of this protocol in a non-Advanced Medical Priority Dispatch System area.

Methods

We designed a before and after study based on a 3-month retrospective assessment of victims of OHCA in 2009, before the implementation of the ALERT protocol in Liege emergency medical communication centre (EMCC), and the prospective evaluation of the same 3 months in 2011, immediately after the implementation.

Results

At the moment of the call, dispatchers were able to identify 233 OHCA in the first period and 235 in the second. Victims were predominantly male (59%, both periods), with mean ages of 64.1 and 63.9 years, respectively. In 2009, only 9.9% victims benefited from bystander CPR, this increased to 22.5% in 2011 (p < 0.0002). The main reasons for protocol under-utilisation were: assistance not offered by the dispatcher (42.3%), caller physically remote from the victim (20.6%). Median time from call to first compression, defined here as no flow time, was 253 s in 2009 and 168 s in 2011 (NS). Ten victims were admitted to hospital after ROSC in 2009 and 13 in 2011 (p = 0.09).

Conclusion

From the beginning and despite its under-utilisation, the ALERT protocol significantly improved the number of patients in whom bystander CPR was attempted.     

Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest

Background

Extracorporeal life support (ECLS) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to conventional cardiopulmonary resuscitation.

Objective

We sought to describe our institution's experience with implementation of ECLS for out-of-hospital and emergency department (ED) cardiac arrests. Our primary outcome was survival to hospital discharge.

Methods

Consecutive patients placed on ECLS in the ED or within one hour of admission after out-of-hospital or ED cardiac arrest were enrolled at two urban academic medical centers in the United States from July 2007–April 2014.

Results

During the study period, 26 patients were included. Average age was 40 ± 15 years, 54% were male, and 42% were white. Initial cardiac rhythms were ventricular fibrillation or pulseless ventricular tachycardia in 42%. The average time from initial cardiac arrest to initiation of ECLS was 77 ± 51 min (range 12–180 min). ECLS cannulation was unsuccessful in two patients. Eighteen (69%) had complications related to ECLS, most commonly bleeding and ischemic events. Four patients (15%) survived to discharge, three of whom were neurologically intact at 6 months.

Conclusion

ECLS shows promise as a rescue strategy for refractory out-of-hospital or ED cardiac arrest but is not without challenges. Further investigations are necessary to refine the technique, patient selection, and ancillary therapeutics.     

The epidemiology of respiratory arrests in a teaching hospital

Aims

We aimed to characterise antecedent causes and outcomes of respiratory arrests occurring within a metropolitan tertiary teaching hospital in Melbourne, Australia.

Methods

We conducted a retrospective audit of respiratory arrests within our hospital over a 6-year period. Data were collected regarding patient characteristics, preceding clinical state, presumed causes and outcomes of arrests. We also compared outcomes of respiratory arrests to that of cardiac arrests occurring over the same period.

Results

We identified 82 respiratory arrests, occurring at a rate of 0.57/1000 inpatient admissions. Pre-existing respiratory, neurologic and cardiac disease was common, as was multi-morbidity. Preceding clinical instability was evident in 39% of arrests, most commonly elevated respiratory rate or progressive hypoxia. Pulmonary oedema was the most common cause of respiratory arrest followed by aspiration, neurologic events, medication side-effects, and tracheostomy-tube complications. In-hospital mortality for respiratory arrests was 25.1%, compared with 74.9% for cardiac arrests (p < 0.001) over the same time period.

Conclusions

Although rare, respiratory arrests are associated with significantly lower in-hospital mortality than cardiac arrests. Further studies are needed to better predict respiratory arrests and identify interventions to reduce incidence and improve outcomes.     

The impact of telemetry on survival of in-hospital cardiac arrests in non-critical care patients

Objective

Since the introduction of telemetry over a half century ago, it has expanded to various units and wards within health care institutions outside of the traditional critical care setting. Little is known on whether routine telemetry use is beneficial in this patient population. The aim of this study was to determine the impact of telemetry monitoring on survival of in-hospital cardiac arrests in patients admitted to non-critical care units.

Methods

A retrospective study of cardiac arrests in patients admitted to non-critical care units within the Winnipeg Regional Health Authority from 2002 to 2006 inclusive was performed. Baseline demographic, cardiac arrest, and outcome data were collected.

Results

Of the total 668 patients, the mean age was 70 ± 14 years with 404 (61%) males. Patients presenting with asystole or pulseless electrical activity (PEA) demonstrated an increased mortality as compared to those presenting with ventricular tachycardia (VT) or ventricular fibrillation (VF). Overall, 268 of 668 patients (40%) survived their initial arrest, 66 (10%) survived to hospital discharge and 49 (7%) survived transfer to another facility. Patients on telemetry vs. no telemetry had higher survival rates immediately following cardiac arrest (66% vs. 34%, OR = 3.67, p = 0.02), as well as higher survival to hospital discharge (30% vs. 6%, OR = 7.17, p = 0.01). Finally, patients with cardiac arrest during the night and early morning benefited proportionally the greatest from telemetry use.

Conclusion

Regardless of whether cardiac arrest was witnessed or unwitnessed, telemetry use was an independent and strong predictor of survival to hospital discharge.     

Impact of the Immediate Life Support course on the incidence and outcome of in-hospital cardiac arrest calls: An observational study over 6 years

Background

The Resuscitation Council (UK) Immediate Life Support (ILS) course provides training in the prevention and management of cardiac arrest. This course was introduced at our institution and we subsequently undertook an analysis to determine its impact on the incidence and outcome of in-hospital cardiac arrest.

Methods

A 6-year prospective audit of 3126 in-hospital emergency alert calls within a multi-site 1200 bedded London teaching hospital following the organisation-wide adoption of the ILS course. Key measures used to detect improvement were the incidence of emergency alert calls, in particular the proportion of calls which were pre-arrest versus cardiac arrest calls, episodes of resuscitations without return of spontaneous circulation, survival to hospital discharge; the proportion of clinical staff who were ILS trained was an important organisational measure.

Results

The total number of emergency alert calls showed no significant change. We observed a reduction in the proportion of calls for cardiac arrests (p < 0.0001; from 85% in 2002 to 45% in 2007), a corresponding increase in the proportion of ‘pre-arrest’ calls (p < 0.0001; from 15% in 2002 to 55% in 2007), a reduction in deaths at cardiac arrest (p = 0.0002) and an increased survival to hospital discharge following an emergency call from 28% in 2004 to 39% in 2007. There was a temporal relationship between the proportion of staff who were ILS trained and outcome.

Conclusion

The introduction of a simple and widespread educational programme was associated with a reduction in both the number of in-hospital cardiac arrests and unsuccessful cardiopulmonary resuscitation attempts.     

Comparison of Medical Priority Dispatch (MPD) and Criteria Based Dispatch (CBD) relating to cardiac arrest calls

Background

Prompt emergency medical service (EMS) system activation with rapid delivery of pre-hospital treatment is essential for patients suffering out-of-hospital cardiac arrest (OHCA). The two most commonly used dispatch tools are Medical Priority Dispatch (MPD) and Criteria Based Dispatch (CBD). We compared cardiac arrest call processing using these two dispatch tools in two different dispatch centres.

Methods

Observational study of adult EMS confirmed (non-EMS witnessed) OHCA calls during one year in Richmond, USA (MPD) and Oslo, Norway (CBD). Patients receiving CPR prior to call, interrupted calls or calls where the caller did not have access to the patients were excluded from analysis. Dispatch logs, ambulance records and digitalized dispatcher and caller voice recordings were compared.

Results

The MPDS-site processed 182 cardiac arrest calls and the CBD-site 232, of which 100 and 140 calls met the inclusion criteria, respectively. The recognition of cardiac arrest was not different in the MPD and CBD systems; 82% vs. 77% (p = 0.42), and pre-EMS arrival CPR instructions were offered to 81% vs. 74% (p = 0.22) of callers, respectively. Time to ambulance dispatch was median (95% confidence interval) 15 (13, 17) vs. 33 (29, 36) seconds (p < 0.001) and time to chest compression delivery; 4.3 (3.7, 4.9) vs. 3.7 (3.0, 4.1) min for the MPD and CBD systems, respectively (p = 0.05).

Conclusion

Pre-arrival CPR instructions were offered faster and more frequently in the CBD system, but in both systems chest compressions were delayed 3–4 min. Earlier recognition of cardiac arrest and improved CPR instructions may facilitate earlier lay rescuer CPR.     

Tau proteins in serum predict neurological outcome after hypoxic brain injury from cardiac arrest: Results of a pilot study

Objective

To conduct a pilot study to evaluate the prognostic potential of serum tau protein measurements to predict neurological outcome 6 months following resuscitation from cardiac arrest.

Methods

In this retrospective observational study, we employed a new ultra sensitive digital immunoassay technology to examine serial serum samples from 25 cardiac arrest patients to examine tau release into serum as a result of brain hypoxia, and probe for its significance predicting six-month neurological outcome. Serial blood samples were obtained from resuscitated cardiac arrest survivors during their first five days in an intensive care unit, and serum total tau was measured. Cerebral function assessments were made using Cerebral Performance Categorization (CPC) at discharge from the ICU and six months later. Tau data were analyzed in the context of 6-month CPC scores.

Results

Tau elevations ranged from modest (<10 pg/mL) to very high (hundreds of pg/mL), and exhibited unexpected bi-modal kinetics in some patients. Early tau elevations appeared within 24 h of cardiac arrest, and delayed elevations appeared after 24–48 h. In patients with delayed elevations, areas under the curves of tau concentration vs. hours since cardiac arrest were highly predictive of 6-month outcome (P < 0.0005).

Conclusion

High-sensitivity serum tau measurements combined with an understanding of tau release kinetics could have utility for hypoxic brain injury assessment and prediction of cerebral function outcome.     

Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device

Background

A recent out-of-hospital cardiac arrest (OHCA) clinical trial showed improved survival to hospital discharge (HD) with favorable neurologic function for patients with cardiac arrest of cardiac origin treated with active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD + ICD) versus standard (S) CPR. The current analysis examined whether treatment with ACD + ITD is more effective than standard (S-CPR) for all cardiac arrests of non-traumatic origin, regardless of the etiology.

Methods

This is a secondary analysis of data from a randomized, prospective, multicenter, intention-to-treat, OHCA clinical trial. Adults with presumed non-traumatic cardiac arrest were enrolled and followed for one year post arrest. The primary endpoint was survival to hospital discharge (HD) with favorable neurologic function (Modified Rankin Scale score ≤ 3).

Results

Between October 2005 and July 2009, 2738 patients were enrolled (S-CPR = 1335; ACD + ITD = 1403). Survival to HD with favorable neurologic function was greater with ACD + ITD compared with S-CPR: 7.9% versus 5.7%, (OR 1.42, 95% CI 1.04, 1.95, p = 0.027). One-year survival was also greater: 7.9% versus 5.7%, (OR 1.43, 95% CI 1.04, 1.96, p = 0.026). Nearly all survivors in both groups had returned to their baseline neurological function by one year. Major adverse event rates were similar between groups.

Conclusions

Treatment of out-of-hospital non-traumatic cardiac arrest patients with ACD + ITD resulted in a significant increase in survival to hospital discharge with favorable neurological function when compared with S-CPR. A significant increase survival rates was observed up to one year after arrest in subjects treated with ACD + ITD, regardless of the etiology of the cardiac arrest.     

Seasonal variability and influence of outdoor temperature on body temperature of cardiac arrest victims

Aim of the study

Mild therapeutic hypothermia is a major advance in post-resuscitation-care. Some questions remain unclear regarding the time to initiate cooling and the time to achieve target temperature below 34 °C. We examined whether seasonal variability of outside temperature influences the body temperature of cardiac arrest victims, and if this might have an effect on outcome.

Methods

Patients with witnessed out-of-hospital cardiac arrests were enrolled retrospectively. Temperature variables from 4 climatic stations in Vienna were provided from the Central Institute for Meteorology and Geodynamics. Depending on the outside temperature at the scene the study participants were assigned to a seasonal group. To compare the seasonal groups a Student's t-test or Mann–Whitney U test was performed as appropriate.

Results

Of 134 patients, 61 suffered their cardiac arrest during winter, with an outside temperature below 10 °C; in 39 patients the event occurred during summer, with an outside temperature above 20 °C. Comparing the tympanic temperature recorded at hospital admission, the median of 36 °C (IQR 35.3–36.3) during summer differed significantly to winter with a median of 34.9 °C (IQR 34–35.6) (p < 0.05). This seasonal alterations in core body temperature had no impact on the time-to-target-temperature, survival rate or neurologic recovery.

Conclusion

The seasonal variability of outside temperature influences body temperature of out-of-hospital cardiac arrest victims.     

Police AED programs: A systematic review and meta-analysis

Background

Approximately 359,400 out-of-hospital cardiac arrests occur in the United States every year, and around 60% of them are treated by emergency medical services (EMS) personnel. In order to alleviate the impact of this public health burden, some communities have trained police officers as first responders so that they can provide cardiopulmonary resuscitation and defibrillation to cardiac arrest patients. This paper is a review of the current literature on the impact of police automated external defibrillators (AEDs) programs in these communities.

Methods and results

A literature search of electronic journal databases was conducted to identify articles that evaluated police AED programs and quantified survival rates. The 10 articles that met the inclusion criteria were very heterogeneous in terms of study design, controlling for confounders, outcome definitions, and comparison groups. Two communities found a statistically significant difference in survival and 6 studies reported a statistically significant difference in time to defibrillation after the implementation of these programs. The weighted mean survival rate of the study groups was higher than that of the control groups (p < 0.001), as was the weighted mean survival rate of the group first shocked by police compared to those first shocked by EMS (39.4% vs. 28.6%, p < 0.001). The pooled relative risk of survival was 1.4 (95% CI: 1.3–1.6).

Conclusions

Though there are many challenges in initiating these programs, this literature review shows that time to defibrillation decreased and survival from out-of-hospital cardiac arrests increased with the implementation of police AED programs.     

Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest

Introduction

We sought to compare characteristics of emergency medical services-treated out-of-hospital cardiac arrests resulting from suspected drug overdose with non-overdose cases and test the relationship between suspected overdose and survival to hospital discharge.

Methods

Data from emergency medical services-treated, non-traumatic out-of-hospital cardiac arrests from 2006 to 2008 and late 2009 to 2011 were obtained from four EMS agencies in the Pittsburgh, Pennsylvania metropolitan area. Case definition for suspected drug overdose was naloxone administration, indication on the patient care report and/or indication by a review of hospital records. Resuscitation parameters included chest compression fraction, rate, and depth and the administration of resuscitation drugs. Demographic and outcome variables compared by suspected overdose status included age, sex, and survival to hospital discharge.

Results

From 2342 treated out-of-hospital cardiac arrests, 180 were suspected overdose cases (7.7%) and were compared to 2162 non-overdose cases. Suspected overdose cases were significantly younger (45 vs. 65, p < 0.001), less likely to be witnessed by a bystander (29% vs. 41%, p < 0.005), and had a higher rate of survival to hospital discharge (19% vs. 12%, p = 0.014) than non-overdoses. Suspected overdose cases had a higher overall chest compression fraction (0.69 vs. 0.67, p = 0.018) and higher probability of adrenaline, sodium bicarbonate, and atropine administration (p < 0.001). Suspected overdose status was predictive of survival to hospital discharge when controlling for other variables (p < 0.001).

Conclusion

Patients with suspected overdose-related out-of-hospital cardiac arrest were younger, received different resuscitative care, and survived more often than non-overdose cases.     

Outcomes of patients with trauma and intraoperative cardiac arrest

Background

Although the occurrence of intraoperative cardiac arrest is rare, it is a severe adverse event with a high mortality rate. Trauma patients have additional causes for intraoperative arrest, and we hypothesised that the survival of trauma patients who experienced intraoperative cardiac arrest would be worse than nontrauma patients who experienced intraoperative cardiac arrest.

Objectives

The aim of the present study was to compare the outcomes of trauma and nontrauma patients after intraoperative cardiac arrest.

Methods

In a tertiary university hospital and trauma centre, the intraoperative cardiac arrest cases were evaluated from January 2007 to December 2009, excluding patients submitted to cardiac surgery. Data were prospectively collected using the Utstein-style. Outcomes among the patients with trauma were compared to the patients without trauma.

Results

We collected data from 81 consecutive intraoperative cardiac arrest cases: 32 with trauma and 49 without trauma. Patients in the trauma group were younger than the patients in the nontrauma group (44 ± 23 vs. 63 ± 17, p < 0.001). Hypovolaemia (63% vs. 35%, p = 0.022) and metabolic/hydroelectrolytic disturbances (41% vs. 2%, p < 0.001) were more likely to cause the cardiac arrest in the trauma group. The first documented arrest rhythm did not differ between the groups, and pulseless electrical activity was the most prevalent rhythm (66% vs. 53%, p = 0.698). The return of spontaneous circulation (47% vs. 63%, p = 0.146) and survival to discharge with favourable neurological outcome (16% vs. 14%, p = 0.869) did not differ between the two groups.

Conclusions

The outcomes did not differ between patients with trauma and nontrauma intraoperative cardiac arrest.     

The quality of cardiopulmonary resuscitation using supraglottic airways and intraosseous devices: A simulation trial

Study objective

To assess whether using interventions such as laryngeal mask airways (LMA) and IO lines lead to improved resuscitation in a simulated cardiac arrest when compared to standard methods of endotracheal intubation (ETI) and central line placement.

Methods

Emergency Medicine residents at a single academic center were grouped into teams of four. Each team participated in two simulated ventricular fibrillation cardiac arrests using a high fidelity simulator. Peripheral IV access was unobtainable. Only ETI supplies and a central line kit were available in one case (control) and in the other case those supplies were replaced by an LMA and an EZ-IO drill kit (experimental). Groups were randomized to which set up they were given first. Data examined included time to airway placement, duration and success rate of airway placement, time to vascular access, time to defibrillation, and percent hands off time.

Results

44 residents in 11 teams participated. Mean time to airway was shorter in the experimental group (122.8 seconds (s) vs. 265.6 s, p = 0.001). Mean duration of airway attempt was also shorter (7.6 s vs. 22.7 s, p = 0.002). Time to access was shorter in the experimental group (49.0 s vs. 194.6 s, p = <0.001). Time to defibrillation and percent hands off time did not significantly differ between the two groups.

Conclusion

Use of an LMA and an IO device led to significantly faster establishment of an airway and vascular access in a simulated cardiac arrest. The variation in devices did not affect time to defibrillation or percent hands off time.     

Body temperature changes are associated with outcomes following in-hospital cardiac arrest and return of spontaneous circulation

Introduction

Spontaneous changes in body temperature after return of circulation (ROSC) from cardiac arrest are common, but the association of these changes with outcomes in hospitalized patients who survive to 24 h post-ROSC is not known. We tested the hypothesis that adults who experience temperature lability in the first 24 h have worse outcomes compared with those who maintain normothermia.

Materials and methods

A prospective observational study from a multicenter registry of cardiac arrests (National Registry of Cardiopulmonary Resuscitation) from 355 US and Canadian hospitals. 14,729 adults with return of circulation from a pulseless cardiac arrest. We excluded those who died or were discharged before 24 h post-event, those made Do-Not-Resuscitate (DNR) within 24 h of event, those that had a preceding trauma, and those with multiple cardiac arrests. Finally, we included only subjects that had both a lowest (T_min) and highest (T_max) body temperature value recorded during the first 24-h after ROSC, resulting in a study sample of 3426 patients.

Results

After adjustment for potential covariates, there was a lower odds of survival in those having an episode of hypothermia (adjusted odds ratio [OR], 0.62; 95% confidence interval [CI], 0.48–0.80), those having an episode of hyperthermia (OR, 0.67; 95% CI, 0.48–0.80), and those having an episode of both (OR, 0.59; 95% CI, 0.39–0.91). Among those who survived to discharge, there was also a lower odds of favorable neurologic performance in those who had an episode of hyperthermia (OR, 0.71; 95% CI, 0.51–0.98).

Conclusions

Episodes of temperature lability following in-hospital resuscitation from cardiac arrest are associated with lower odds of surviving to discharge. Hyperthermia is also associated with fewer patients leaving the hospital with favorable neurologic performance. Further studies should identify whether therapeutic control over changes in body temperature after in-hospital cardiac arrest improves outcomes.     

Improving the quality of cardiopulmonary resuscitation by training dedicated cardiac arrest teams incorporating a mechanical load-distributing device at the emergency department

Objective

Determine if implementing cardiac arrest teams trained with a ‘pit-crew’ protocol incorporating a load-distributing band mechanical CPR device (Autopulse™ ZOLL) improves the quality of CPR, as determined by no-flow ratio (NFR) in the first 10 min of resuscitation.

Methods

A phased, prospective, non-randomized, before–after cohort evaluation. Data collection was from April 2008 to February 2011. There were 100 before and 148 after cases. Continuous video and chest compression data of all study subjects were analyzed. All non-traumatic, collapsed patients aged 18 years and above presenting to the emergency department were eligible. Primary outcome was NFR. Secondary outcomes were return of spontaneous circulation (ROSC), survival to hospital admission and neurological outcome at discharge.

Main results

After implementation, mean total NFR for the first 5 min decreased from 0.42 to 0.27 (decrease = 0.15, 95% CI 0.10–0.19, p < 0.005), and from 0.24 to 0.18 (decrease = 0.06, 95% CI 0.01–0.11, p = 0.02) for the next 5 min. The mean time taken to apply Autopulse™ decreased from 208.8 s to 141.6 s (decrease = 67.2, 95% CI, 22.3–112.1, p < 0.005). The mean CPR ratio increased from 46.4% to 88.4% (increase = 41.9%, 95% CI 36.9–46.9, p < 0.005) and the mean total NFR for the first 10 min decreased from 0.33 to 0.23 (decrease = 0.10, 95% CI 0.07–0.14, p < 0.005).

Conclusion

Implementation of cardiac arrest teams was associated with a reduction in NFR in the first 10 min of resuscitation. Training cardiac arrest teams in a ‘pit-crew’ protocol may improve the quality of CPR at the ED.     

Epidemiology and outcomes of in-hospital cardiac arrest in critically ill children across hospitals of varied center volume: A multi-center analysis

Objective

To describe epidemiology and outcomes associated with cardiac arrest among critically ill children across hospitals of varying center volumes.

Methods

Patients <18 years of age in the Virtual PICU Systems (VPS, LLC) Database (2009–2013) were included. Patients with both cardiac and non-cardiac diagnoses were included. Data on demographics, patient diagnosis, cardiac arrest, severity of illness and outcomes were collected. Hierarchical cluster analysis was performed to categorize all the participating centers into low, low-medium, high-medium, and high volume groups using the center volume characteristics (annual hospital discharges per center, annual extracorporeal membrane oxygenation per center, and annual mechanical ventilators per center). Multivariable models were used to evaluate association of center volume with incidence of cardiac arrest, and mortality after cardiac arrest, adjusting for patient and center characteristics.

Results

Of 329,982 patients (108 centers), 2.2% (n = 7390) patients had cardiac arrest with an associated mortality of 35% (n = 2586). In multivariable models controlling for patient and center characteristics, center volume was not associated with either the incidence of cardiac arrest (OR: 1.00; 95% CI: 0.95–1.06; p = 0.98), or mortality in those with cardiac arrest (OR: 0.93; 95% CI: 0.82–1.06; p = 0.27). These associations were similar across cardiac and non-cardiac disease categories. Furthermore, we demonstrated that there was no correlation between incidence of cardiac arrest and mortality in those with cardiac arrest across different study hospitals in adjusted models.

Conclusions

Both incidence of cardiac arrest, and mortality in those with cardiac arrest vary substantially across hospitals. However, center volume is not associated with either of these outcomes, after adjusting for patient and center characteristics.     

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.