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Nazeha N, Mao DR, Hong D, Shahidah N, Chua ISY, Ng YY, Leong BSH, Tiah L, Chia MYC, Ng WM, Doctor NE, Ong MEH, Graves N. Cost-effectiveness analysis of a 'Termination of Resuscitation' protocol for the management of out-of-hospital cardiac arrest. Resuscitation 2024; 202:110323. [PMID: 39029582 DOI: 10.1016/j.resuscitation.2024.110323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 07/09/2024] [Accepted: 07/12/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND Historically in Singapore, all out-of-hospital cardiac arrests (OHCA) were transported to hospital for pronouncement of death. A 'Termination of Resuscitation' (TOR) protocol, implemented from 2019 onwards, enables emergency responders to pronounce death at-scene in Singapore. This study aims to evaluate the cost-effectiveness of the TOR protocol for OHCA management. METHODS Adopting a healthcare provider's perspective, a Markov model was developed to evaluate three competing options: No TOR, Observed TOR reflecting existing practice, and Full TOR if TOR is exercised fully. The model had a cycle duration of 30 days after the initial state of having a cardiac arrest, and was evaluated over a 10-year time horizon. Probabilistic sensitivity analysis was performed to account for uncertainties. The costs per quality adjusted life years (QALY) was calculated. RESULTS A total of 3,695 OHCA cases eligible for the TOR protocol were analysed; mean age of 73.0 ± 15.5 years. For every 10,000 hypothetical patients, Observed TOR and Full TOR had more deaths by approximately 19 and 31 patients, respectively, compared to No TOR. Full TOR had the least costs and QALYs at $19,633,369 (95% Uncertainty Interval (UI) 19,469,973 to 19,796,764) and 0 QALYs. If TOR is exercised for every eligible case, it could expect to save approximately $400,440 per QALY loss compared to No TOR, and $821,151 per QALY loss compared to Observed TOR. CONCLUSION The application of the TOR protocol for the management of OHCA was found to be cost-effective within acceptable willingness-to-pay thresholds, providing some justification for sustainable adoption.
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Affiliation(s)
- Nuraini Nazeha
- Health Services and Systems Research, Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
| | - Desmond Renhao Mao
- Department of Acute and Emergency Care, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Dehan Hong
- Emergency Medical Services Department, Singapore Civil Defence Force, 91 Ubi Ave 4, Singapore 408827, Singapore
| | - Nur Shahidah
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
| | - Ivan Si Yong Chua
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Yih Yng Ng
- Department of Preventive and Population Medicine, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, Singapore 308433, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Rd, Singapore 308207, Singapore
| | - Benjamin S H Leong
- Emergency Medicine Department, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
| | - Ling Tiah
- Accident and Emergency, Changi General Hospital, 2 Simei St 3, Singapore 529889, Singapore
| | - Michael Y C Chia
- Emergency Department, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, Singapore 308433, Singapore
| | - Wei Ming Ng
- Emergency Medicine Department, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore 609606, Singapore
| | - Nausheen E Doctor
- Department of Emergency Medicine, Sengkang General Hospital, 110 Sengkang E Wy, Singapore 544886, Singapore
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore; Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Nicholas Graves
- Health Services and Systems Research, Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore.
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Smyth MA, Gunson I, Coppola A, Johnson S, Greif R, Lauridsen KG, Taylor-Philips S, Perkins GD. Termination of Resuscitation Rules and Survival Among Patients With Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2420040. [PMID: 38958975 PMCID: PMC11222995 DOI: 10.1001/jamanetworkopen.2024.20040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/02/2024] [Indexed: 07/04/2024] Open
Abstract
Importance Termination of resuscitation (TOR) rules may help guide prehospital decisions to stop resuscitation, with potential effects on patient outcomes and health resource use. Rules with high sensitivity risk increasing inappropriate transport of nonsurvivors, while rules without excellent specificity risk missed survivors. Further examination of the performance of TOR rules in estimating survival of out-of-hospital cardiac arrest (OHCA) is needed. Objective To determine whether TOR rules can accurately identify patients who will not survive an OHCA. Data Sources For this systematic review and meta-analysis, the MEDLINE, Embase, CINAHL, Cochrane Library, and Web of Science databases were searched from database inception up to January 11, 2024. There were no restrictions on language, publication date, or time frame of the study. Study Selection Two reviewers independently screened records, first by title and abstract and then by full text. Randomized clinical trials, case-control studies, cohort studies, cross-sectional studies, retrospective analyses, and modeling studies were included. Systematic reviews and meta-analyses were reviewed to identify primary studies. Studies predicting outcomes other than death, in-hospital studies, animal studies, and non-peer-reviewed studies were excluded. Data Extraction and Synthesis Data were extracted by one reviewer and checked by a second. Two reviewers assessed risk of bias using the Revised Quality Assessment Tool for Diagnostic Accuracy Studies. Cochrane Screening and Diagnostic Tests Methods Group recommendations were followed when conducting a bivariate random-effects meta-analysis. This review followed the Preferred Reporting Items for a Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) statement and is registered with the International Prospective Register of Systematic Reviews (CRD42019131010). Main Outcomes and Measures Sensitivity and specificity tables with 95% CIs and bivariate summary receiver operating characteristic (SROC) curves were produced. Estimates of effects at different prevalence levels were calculated. These estimates were used to evaluate the practical implications of TOR rule use at different prevalence levels. Results This review included 43 nonrandomized studies published between 1993 and 2023, addressing 29 TOR rules and involving 1 125 587 cases. Fifteen studies reported the derivation of 20 TOR rules. Thirty-three studies reported external data validations of 17 TOR rules. Seven TOR rules had data to facilitate meta-analysis. One clinical study was identified. The universal termination of resuscitation rule had the best performance, with pooled sensitivity of 0.62 (95% CI, 0.54-0.71), pooled specificity of 0.88 (95% CI, 0.82-0.94), and a diagnostic odds ratio of 20.45 (95% CI, 13.15-31.83). Conclusions and Relevance In this review, there was insufficient robust evidence to support widespread implementation of TOR rules in clinical practice. These findings suggest that adoption of TOR rules may lead to missed survivors and increased resource utilization.
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Affiliation(s)
- Michael A. Smyth
- Medical School, University of Warwick, Coventry, England
- University Hospital Coventry and Warwickshire NHS Trust, Coventry, England
| | - Imogen Gunson
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, England
| | - Alison Coppola
- University Hospitals Plymouth NHS Trust, Plymouth, England
| | | | - Robert Greif
- Department of Anesthesiology and Pain Therapy, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
- School of Medicine, Sigmund Freud University, Vienna, Austria
| | - Kasper G. Lauridsen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Medicine, Randers Regional Hospital, Randers, Denmark
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Gavin D. Perkins
- Medical School, University of Warwick, Coventry, England
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
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Cavanagh N, Blanchard IE, Weiss D, Tavares W. Looking back to inform the future: a review of published paramedicine research. BMC Health Serv Res 2023; 23:108. [PMID: 36732779 PMCID: PMC9893690 DOI: 10.1186/s12913-022-08893-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/28/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Paramedicine has evolved in ways that may outpace the science informing these changes. Examining the scholarly pursuits of paramedicine may provide insights into the historical academic focus, which may inform future endeavors and evolution of paramedicine. The objective of this study was to explore the existing discourse in paramedicine research to reflect on the academic pursuits of this community. METHODS We searched Medline, Embase, CINAHL, Google Scholar and Web of Science from January, 2006 to April, 2019. We further refined the yield using a ranking formula that prioritized journals most relevant to paramedicine, then sampled randomly in two-year clusters for full text review. We extracted literature type, study topic and context, then used elements of qualitative content, thematic, and discourse analysis to further describe the sample. RESULTS The initial search yielded 99,124 citations, leaving 54,638 after removing duplicates and 7084 relevant articles from nine journals after ranking. Subsequently, 2058 articles were included for topic categorization, and 241 papers were included for full text analysis after random sampling. Overall, this literature reveals: 1) a relatively narrow topic focus, given the majority of research has concentrated on general operational activities and specific clinical conditions and interventions (e.g., resuscitation, airway management, etc.); 2) a limited methodological (and possibly philosophical) focus, given that most were observational studies (e.g., cohort, case control, and case series) or editorial/commentary; 3) a variety of observed trajectories of academic attention, indicating where the evolution of paramedicine is evident, areas where scope of practice is uncertain, and areas that aim to improve skills historically considered core to paramedic clinical practice. CONCLUSIONS Included articles suggest a relatively narrow topic focus, a limited methodological focus, and observed trajectories of academic attention indicating where research pursuits and priorities are shifting. We have highlighted that the academic focus may require an alignment with aspirational and direction setting documents aimed at developing paramedicine. This review may be a snapshot of scholarly activity that reflects a young medically directed profession and systems focusing on a few high acuity conditions, with aspirations of professional autonomy contributing to the health and social well-being of communities.
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Affiliation(s)
- N. Cavanagh
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta Canada
| | - I. E. Blanchard
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta Canada
| | - D. Weiss
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada
| | - W. Tavares
- grid.512795.dThe Wilson Centre, Department of Medicine, University of Toronto/University Health Network, Toronto, Ontario Canada ,grid.17063.330000 0001 2157 2938Department of Health and Society, University of Toronto, Toronto, Ontario Canada ,York Region Paramedic and Senior Services, Community Health Services Department, Regional Municipality of York, Newmarket, Ontario Canada
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Abstract
PURPOSE OF REVIEW Out-of-hospital cardiac arrest (OHCA) is the most devastating and time-critical medical emergency. Survival after OHCA requires an integrated system of care, of which transport by emergency medical services is an integral component. The transport system serves to commence and ensure uninterrupted high-quality resuscitation in suitable patients who would benefit, terminate resuscitation in those that do not, provide critical interventions, as well as convey patients to the next appropriate venue of care. We review recent evidence surrounding contemporary issues in the transport of OHCA, relating to who, where, when and how to transport these patients. RECENT FINDINGS We examine the clinical and systems-related evidence behind issues including: contemporary approaches to field termination of resuscitation in patients in whom continued resuscitation and transport to hospital would be medically futile, OHCA patients and organ donation, on-scene versus intra-transport resuscitation, significance of response time, intra-transport interventions (mechanical chest compression, targeted temperature management, ECMO-facilitated cardiopulmonary resuscitation), OHCA in high-rise locations and cardiac arrest centers. We highlight gaps in current knowledge and areas of active research. SUMMARY There remains limited evidence to guide some decisions in transporting the OHCA patient. Evidence is urgently needed to elucidate the roles of cardiac arrest centers and ECPR in OHCA.
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Nazeha N, Ong MEH, Limkakeng AT, Ye JJ, Joiner AP, Blewer A, Shahidah N, Nadarajan GD, Mao DR, Graves N. A hypothetical implementation of 'Termination of Resuscitation' protocol for out-of-hospital cardiac arrest. Resusc Plus 2021; 6:100092. [PMID: 34223357 PMCID: PMC8244430 DOI: 10.1016/j.resplu.2021.100092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/28/2021] [Indexed: 11/29/2022] Open
Abstract
A proportion of out of hospital cardiac arrests are associated with poor prognoses. Prolonged resuscitation on medically futile cases results in financial burden for the health system and distress for health care workers. ‘Termination of Resuscitation’ protocols enable ceasing resuscitation efforts for certain cases. Successfully adopting a protocol over existing practices demonstrates fewer cases transported to hospital, fewer emergency treatments and fewer inpatient bed days used. The protocol can lead to reduced costs and fewer non-beneficial hospital admissions.
Background Out-of-hospital cardiac arrests with negligible chance of survival are routinely transported to hospital and many are pronounced dead thereafter. This leads to some potentially avoidable costs. The ‘Termination of Resuscitation’ protocol allows paramedics to terminate resuscitation efforts onsite for medically futile cases. This study estimates the changes in frequency of costly events that might occur when the protocol is applied to out-of-hospital cardiac arrests, as compared to existing practice. Methods We used Singapore data from the Pan-Asian Resuscitation Outcomes Study, from 1 Jan 2014 to 31 Dec 2017. A Markov model was developed to summarise the events that would occur in two scenarios, existing practice and the implementation of a Termination of Resuscitation protocol. The model was evaluated for 10,000 hypothetical patients with a cycle duration of 30 days after having a cardiac arrest. Probabilistic sensitivity analysis accounted for uncertainties in the outcomes: number of urgent transports and emergency treatments, inpatient bed days, and total number of deaths. Results For every 10,000 patients, existing practice resulted in 1118 (95% Uncertainty Interval 1117 to 1119) additional urgent transports to hospital and subsequent emergency treatments. There were 93 (95% Uncertainty Interval 66 to 120) extra inpatient bed days used, and 3 fewer deaths (95% Uncertainty Interval 2 to 4) in comparison to using the protocol. Conclusion The findings provide some evidence for adopting the Termination of Resuscitation protocol. This policy could lead to a reduction in costs and non-beneficial hospital admissions, however there may be a small increase in the number of avoidable deaths.
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Affiliation(s)
- Nuraini Nazeha
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Jinny J Ye
- Department of Emergency Medicine, Durham Veterans Affairs Medical Center, Durham, NC, United States
| | - Anjni Patel Joiner
- Division of Emergency Medicine, Duke University Hospital, Durham, NC, United States.,Duke Global Health Institute, Duke University, Durham, NC, United States
| | - Audrey Blewer
- Department of Family Medicine and Community Health and Department of Population Health Sciences, Duke University School of Medicine, NC, United States
| | - Nur Shahidah
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Desmond Renhao Mao
- Department of Acute and Emergency Care, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Nicholas Graves
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
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Prehospital Disposition and Patient Outcomes in Cardiac Arrest AFTER Resuscitation Termination Protocol Change in an Urban Setting. Prehosp Disaster Med 2021; 35:285-292. [PMID: 32308184 DOI: 10.1017/s1049023x20000473] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Out-of-hospital cardiac arrest (OHCA) is a leading cause of death in the United States, and efforts have been made to develop termination of resuscitation protocols utilizing clinical criteria predictive of successful resuscitation and survival to discharge. A termination of resuscitation protocol utilizing longer resuscitation time and end-tidal carbon dioxide (EtCO2) monitoring criteria for termination was implemented for Emergency Medical Service (EMS) providers in an urban prehospital system in 2017. This study examines the effect the modified termination of resuscitation protocol had on rates of patient transport to a hospital, return of spontaneous circulation (ROSC), and survival to discharge. METHODS A retrospective analysis was performed utilizing data from the Cardiac Arrest Registry to Enhance Survival (CARES) database. A total of 1,005 prehospital cardiac arrest patients 18 years and older from 2016 through 2017 were included in the analysis. Patients with traumatic cardiac arrest or had valid do-not-resuscitate orders were excluded. Unadjusted analysis using chi-square statistics was performed, including an analysis stratified by Utstein style reporting. Adjusted analysis was also performed using logistic regression with multiple imputation for missing values. RESULTS Unadjusted analysis showed a significant decrease in ROSC on emergency department (ED) arrival (30% versus 13%; P <.001) following the change in protocol. There was no significant difference in patient transport rate (62%) and a statistically non-significant decrease in overall survival (15% versus 11%). When stratified by Utstein style analysis, statistically significant decreases in ED arrival with ROSC were seen for unwitnessed asystolic, as well as bystander witnessed asystolic, pulseless electrical activity (PEA), and shockable OHCA. Adjusted analysis showed a decreased likelihood of ROSC with the protocol change (0.337; 95% CI, 0.235-0.482). CONCLUSION The modification of termination of resuscitation protocol was not associated with a statistically significant change in transport rate or survival. A significant decrease in rate of arrivals to the ED with ROSC was seen, particularly for bystander witnessed OHCA.
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Jung H, Lee MJ, Cho JW, Lee SH, Lee SH, Mun YH, Chung HS, Kim YH, Kim GM, Park SY, Jeon JC, Kim C. External validation of multimodal termination of resuscitation rules for out-of-hospital cardiac arrest patients in the COVID-19 era. Scand J Trauma Resusc Emerg Med 2021; 29:19. [PMID: 33504366 PMCID: PMC7838848 DOI: 10.1186/s13049-021-00834-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 01/12/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Futile resuscitation for out-of-hospital cardiac arrest (OHCA) patients in the coronavirus disease (COVID)-19 era can lead to risk of disease transmission and unnecessary transport. Various existing basic or advanced life support (BLS or ALS, respectively) rules for the termination of resuscitation (TOR) have been derived and validated in North America and Asian countries. This study aimed to evaluate the external validation of these rules in predicting the survival outcomes of OHCA patients in the COVID-19 era. METHODS This was a multicenter observational study using the WinCOVID-19 Daegu registry data collected during February 18-March 31, 2020. The subjects were patients who showed cardiac arrest of presumed cardiac etiology. The outcomes of each rule were compared to the actual patient survival outcomes. The sensitivity, specificity, false positive value (FPV), and positive predictive value (PPV) of each TOR rule were evaluated. RESULTS In total, 170 of the 184 OHCA patients were eligible and evaluated. TOR was recommended for 122 patients based on the international basic life support termination of resuscitation (BLS-TOR) rule, which showed 85% specificity, 74% sensitivity, 0.8% FPV, and 99% PPV for predicting unfavorable survival outcomes. When the traditional BLS-TOR rules and KoCARC TOR rule II were applied to our registry, one patient met the TOR criteria but survived at hospital discharge. With regard to the FPV (upper limit of 95% confidence interval < 5%), specificity (100%), and PPV (> 99%) criteria, only the KoCARC TOR rule I, which included a combination of three factors including not being witnessed by emergency medical technicians, presenting with an asystole at the scene, and not experiencing prehospital shock delivery or return of spontaneous circulation, was found to be superior to all other TOR rules. CONCLUSION Among the previous nine BLS and ALS TOR rules, KoCARC TOR rule I was most suitable for predicting poor survival outcomes and showed improved diagnostic performance. Further research on variations in resources and treatment protocols among facilities, regions, and cultures will be useful in determining the feasibility of TOR rules for COVID-19 patients worldwide.
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Affiliation(s)
- Haewon Jung
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, 680, Gukchaebosang-ro, Jung-gu, Daegu, 41944 Republic of Korea
| | - Mi Jin Lee
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, 680, Gukchaebosang-ro, Jung-gu, Daegu, 41944 Republic of Korea
| | - Jae Wan Cho
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, 680, Gukchaebosang-ro, Jung-gu, Daegu, 41944 Republic of Korea
| | - Sang Hun Lee
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Suk Hee Lee
- Department of Emergency Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - You Ho Mun
- Department of Emergency Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Han-sol Chung
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, 680, Gukchaebosang-ro, Jung-gu, Daegu, 41944 Republic of Korea
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | - Yang Hun Kim
- Department of Emergency Medicine, Daegu Fatima Hospital, Daegu, Republic of Korea
| | - Gyun Moo Kim
- Department of Emergency Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Sin-youl Park
- Department of Emergency Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Jae Cheon Jeon
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Changho Kim
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, 680, Gukchaebosang-ro, Jung-gu, Daegu, 41944 Republic of Korea
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | - on behalf of the WinCOVID-19 consortium
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, 680, Gukchaebosang-ro, Jung-gu, Daegu, 41944 Republic of Korea
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
- Department of Emergency Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
- Department of Emergency Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
- Department of Emergency Medicine, Daegu Fatima Hospital, Daegu, Republic of Korea
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Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Hsieh MJ, Iwami T, Lauridsen KG, Lockey AS, Ma MHM, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn JC. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S222-S283. [PMID: 33084395 DOI: 10.1161/cir.0000000000000896] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.
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Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Hsieh MJ, Iwami T, Lauridsen KG, Lockey AS, Ma MHM, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn JC, Baldi E, Beck S, Beckers SK, Blewer AL, Boulton A, Cheng-Heng L, Yang CW, Coppola A, Dainty KN, Damjanovic D, Djärv T, Donoghue A, Georgiou M, Gunson I, Krob JL, Kuzovlev A, Ko YC, Leary M, Lin Y, Mancini ME, Matsuyama T, Navarro K, Nehme Z, Orkin AM, Pellis T, Pflanzl-Knizacek L, Pisapia L, Saviani M, Sawyer T, Scapigliati A, Schnaubelt S, Scholefield B, Semeraro F, Shammet S, Smyth MA, Ward A, Zace D. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156:A188-A239. [PMID: 33098918 DOI: 10.1016/j.resuscitation.2020.09.014] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.
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Nas J, Kleinnibbelink G, Hannink G, Navarese EP, van Royen N, de Boer MJ, Wik L, Bonnes JL, Brouwer MA. Diagnostic performance of the basic and advanced life support termination of resuscitation rules: A systematic review and diagnostic meta-analysis. Resuscitation 2019; 148:3-13. [PMID: 31887367 DOI: 10.1016/j.resuscitation.2019.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/14/2019] [Accepted: 12/18/2019] [Indexed: 01/22/2023]
Abstract
AIM To minimize termination of resuscitation (TOR) in potential survivors, the desired positive predictive value (PPV) for mortality and specificity of universal TOR-rules are ≥99%. In lack of a quantitative summary of the collective evidence, we performed a diagnostic meta-analysis to provide an overall estimate of the performance of the basic and advanced life support (BLS and ALS) termination rules. DATA SOURCES We searched PubMed/EMBASE/Web-of-Science/CINAHL and Cochrane (until September 2019) for studies on either or both TOR-rules in non-traumatic, adult cardiac arrest. PRISMA-DTA-guidelines were followed. RESULTS There were 19 studies: 16 reported on the BLS-rule (205.073 patients, TOR-advice in 57%), 11 on the ALS-rule (161.850 patients, TOR-advice in 24%). Pooled specificities were 0.95 (0.89-0.98) and 0.98 (0.95-1.00) respectively, with a PPV of 0.99 (0.99-1.00) and 1.00 (0.99-1.00). Specificities were significantly lower in non-Western than Western regions: 0.84 (0.73-0.92) vs. 0.99 (0.97-0.99), p < 0.001 for the BLS rule. For the ALS-rule, specificities were 0.94 (0.87-0.97) vs. 1.00 (0.99-1.00), p < 0.001. For non-Western regions, 16 (BLS) or 6 (ALS) out of 100 potential survivors met the TOR-criteria. Meta-regression demonstrated decreasing performance in settings with lower rates of in-field shocks. CONCLUSIONS Despite an overall high PPV, this meta-analysis highlights a clinically important variation in diagnostic performance of the BLS and ALS TOR-rules. Lower specificity and PPV were seen in non-Western regions, and populations with lower rates of in-field defibrillation. Improved insight in the varying diagnostic performance is highly needed, and local validation of the rules is warranted to prevent in-field termination of potential survivors.
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Affiliation(s)
- Joris Nas
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands.
| | - Geert Kleinnibbelink
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands; Institute for Sport and Exercise Sciences, Liverpool John Moores University, 3 Byrom Street, L3 3AF Liverpool, UK
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eliano P Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Cardiovascular Institute Mater Dei Hospital, Bari, Italy; SIRIO MEDICINE Cardiovascular Network, Italy; Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Niels van Royen
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - Menko-Jan de Boer
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - Lars Wik
- Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS), Oslo University Hospital, Oslo, Norway
| | - Judith L Bonnes
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - Marc A Brouwer
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
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Abstract
Sudden out-of-hospital cardiac arrest is the most time-critical medical emergency. In the second paper of this Series on out-of-hospital cardiac arrest, we considered important issues in the prehospital management of cardiac arrest. Successful resuscitation relies on a strong chain of survival with the community, dispatch centre, ambulance, and hospital working together. Early cardiopulmonary resuscitation and defibrillation has the greatest impact on survival. If the community response does not restart the heart, resuscitation is continued by emergency medical services' staff. However, the best approaches for airway management and the effectiveness of currently used drug treatments are uncertain. Prognostic factors and rules for termination of resuscitation could guide the duration of a resuscitation attempt and decision to transport to hospital. If return of spontaneous circulation is achieved, the focus of treatment shifts to stabilisation, restoration of normal physiological parameters, and transportation to hospital for ongoing care.
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Affiliation(s)
- Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Health Services and Systems Research, Duke-NUS Medical School, Singapore.
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Alain Cariou
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris, France; Paris Descartes University, Paris, France
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Mao DRH, Ong MEH, Bang C, Salim MDT, Ng YY, Lie DA. Psychological Comfort of Paramedics with Field Death Pronouncement: A National Asian Study to Prepare Paramedics for Field Termination of Resuscitation. PREHOSP EMERG CARE 2017; 22:260-265. [DOI: 10.1080/10903127.2017.1376132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Tataris KL, Richards CT, Stein-Spencer L, Ryan S, Lazzara P, Weber JM. EMS Provider Perceptions on Termination of Resuscitation in a Large, Urban EMS System. PREHOSP EMERG CARE 2017; 21:610-615. [PMID: 28481722 DOI: 10.1080/10903127.2017.1317891] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Despite the value of out-of-hospital Termination of Resuscitation (TOR) and the scientific evidence in favor of this practice, TOR has not been uniformly adopted or consistently practiced in EMS systems. Previous focus group studies have identified multiple barriers to implementation of out of hospital TOR but existing literature on EMS provider perceptions is limited. We sought to identify EMS providers' perceived barriers to performing out-of-hospital TOR in a large urban EMS system. METHODS The Chicago EMS System is a regional collaborative of EMS physicians, nurses and provider agencies, including the Chicago Fire Department (CFD), which provides exclusive emergency response for 9-1-1 calls in Chicago. CFD is an urban, fire-based EMS agency with a tiered response, with fire-fighter EMTs and paramedics providing initial care, and single role paramedics providing supplemental care and transport. A 2-page written survey was distributed to understand providers' experiences with managing OHCA and perceived barriers to TOR to inform subsequent improvements in protocol development and education. RESULTS Of 3500 EMS providers that received the survey, 2309 were completed (66%). Survey respondent demographics were fire-fighter/EMTB (69%), fire-fighter/paramedic (14%), and single role paramedic (17%). The most frequent barrier to field TOR was scene safety (86%). The most common safety issue identified was family reaction to TOR (68%) and many providers felt threatened by family when trying to perform TOR (38%). Providers with a higher career numbers of OHCA were more likely to have felt threatened by the family (OR 6.70, 95% CI 2.99-15.00) and single role paramedics were more likely than FF/EMTBs to have felt threatened (OR 3.34, 95% CI 2.65-4.22). Barriers to delivering a death notification after TOR, include being uncomfortable or threatened with possible family reaction (52%) and family asking to continue the resuscitation (45%). There was lack of formal prior death notification training, the majority learned from colleagues through on the job training. CONCLUSIONS Our study identifies scene safety, death notification delivery, and lack of formal training in death notification as barriers that EMS providers face while performing TOR in a large urban EMS system. These findings informed educational and operational initiatives to overcome the identified provider level issues and improve compliance with TOR policies.
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Fan KL, Leung LP. Outcomes of Cardiac Arrest in Residential Care Homes for the Elderly in Hong Kong. PREHOSP EMERG CARE 2017; 21:709-714. [PMID: 28467148 DOI: 10.1080/10903127.2017.1317890] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Studies done in the 1990's suggested nursing home residents with cardiac arrest had minimal chance of survival and resuscitation was not recommended. More recent studies showed opposing results. In Hong Kong, the proportion of elderly living in the residential care homes for the elderly is increasing. There is no study of out-of-hospital cardiac arrest outcomes in this population. This study aimed at evaluating the prognosis of out-of-hospital cardiac arrest occurring in the residential care homes for the elderly. It is hoped that the findings may inform the local emergency medical service concerning the issue of futility of resuscitating the residents with cardiac arrest in the residential care homes. METHODS This study was a retrospective analysis of a database of all patients aged 65 years or above with atraumatic out-of-hospital cardiac arrest and who were attended by the emergency medical service in a 12-month period. Data in the database were prospectively collected by the emergency medical service. The characteristics of patients and cardiac arrests, timeliness of the emergency medical service, and survival were analyzed. Comparison was made between elderly living in and not living in the residential care homes. Predictors of survival were evaluated with logistic regression. RESULTS 3919 patients aged ≥ 65 years were analyzed. There were 1506 cases of cardiac arrest occurring in the residential care homes for the elderly. Resuscitation was discontinued at the emergency department in over 70% of these cases. The survival to hospital admission rate and the 30-day survival rate were 9.6% and 0.3% respectively. Both were lower than patients not residing in the residential care homes. Younger age, witnessed arrest, bystander defibrillation, and shorter call to ED interval were associated with higher chance of surviving to hospital admission. CONCLUSION Elderly suffering from cardiac arrest in residential care homes had a poor chance of survival. Except age, witnessed arrest, bystander defibrillation, and call to ED interval are modifiable predictors of survival. It is inappropriate to declare that resuscitating elderly in residential care homes is futile unless those factors have been fully addressed.
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Blood lactate concentration after cardiac arrest resulting from myocardial infarction and outcome. Am J Emerg Med 2016; 34:1311-3. [DOI: 10.1016/j.ajem.2016.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 04/26/2016] [Indexed: 11/24/2022] Open
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