Should We Terminate Termination of Resuscitation Rules?

August 29, 2024

Written by Amanda Mathews

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This systematic review and meta-analysis of 43 nonrandomized studies over 30 years looking at termination of resuscitation (TOR) rules in out of hospital cardiac arrest (OHCA) found that there was insufficient evidence to support widespread implementation of TOR rules in clinical practice, as this may lead to missed survivors.

Stay and work or grab and go?
TOR rules are used in OHCA to determine which patients would benefit from further transport for hospital care versus patients for whom resuscitation can be terminated in the field. These rules try to balance patient survival versus resource utilization. Other studies estimate there are thousands of futile transports a year resulting in high healthcare costs and taking prehospital transport crews out of circulation.

Researchers utilized database searches to identify 43 studies over 30 years (1993-2023) involving 1.1 million cases of OHCA from 11 different countries. All studies identified were nonrandomized, and there was substantial variation in study populations and prevalence in OHCA. TOR rules identified in this study included 20 unique TOR rules derived from low-certainty evidence and external data validations of 17 previously established TOR rules.

The universal termination of resuscitation (UTOR) rule had the best performance, with a pooled sensitivity of 0.62 (95%CI 0.54-0.71) and pooled specificity of 0.88 (95%CI 0.82-0.94). Depending on the survival rate in OHCA in a population (from 8-12%), this means the UTOR rule would miss between 1-1.5% of potential survivors which would be an unacceptably high miss rate.

How will this change my practice?
This study will not change my hospital-based practices. There is significant heterogeneity in these studies, and even the best rule still had an unacceptably high rate of missed survivors. I think it is reasonable to work with your local EMS agencies to establish best practices regarding transport of OHCA in your area, being mindful of local prevalence, survival rates, and resources available.

Source
Termination of Resuscitation Rules and Survival Among Patients With Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2024 Jul 1;7(7):e2420040. doi: 10.1001/jamanetworkopen.2024.20040. PMID: 38958975; PMCID: PMC11222995.