Termination of Resuscitation: Reducing Futile Transportation to Hospital for Out of Hospital Cardiac Arrests of Cardiac Aetiology

House, Matt (2017) Termination of Resuscitation: Reducing Futile Transportation to Hospital for Out of Hospital Cardiac Arrests of Cardiac Aetiology. Doctoral thesis, Northumbria University.

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Abstract

Background:
UK ambulance clinicians are able only to terminate resuscitation attempts that have resulted in an asystolic (flat line) cardiac rhythm, following twenty minutes of advanced life support. All other attempted resuscitations must be transported to hospital for further treatment. Despite this, there are still large numbers of patients transported to hospital who do not survive.

Thirteen studies were identified that purported to validate termination of resuscitation guidelines. This evidence could not be used to reduce the number of futile transportations to hospital of adult cardiac arrests of presumed cardiac aetiology within the geographical area of interest, due the variances in emergency medical systems.

Methods:
Binominal logistic regression identified variables associated with outcomes in a dataset of 4,870 adult cardiac arrests of presumed cardiac aetiology (Phase 1). The clinical decision rule was validated retrospectively against an independent dataset of 2139 patients (Phase 2). It was then validated prospectively (Phase 3). Finally, the financial benefit of introducing the guideline was assessed. Assumptions were made on the potential resources required to treat each patient and the impact from an acute care perspective was assessed as the difference in cost when applying the guideline, compared to current practice.

Results:
The clinical decision rule (terminate on scene if the initial rhythm was not shockable and there is no return of circulation) was shown in Phase 1 to have a specificity of 99.0% (95% CI: 97.7% to 99.7%) and sensitivity of 53.1% (95% CI: 51.6% to 54.6%). The transport rate was 52.4%. There were five (0.2%) unexpected survivors. This compared favourably with existing guidelines. In Phase 2 the guideline recommended termination for 832 patients. Of these, 829 (99.6%) died and three (0.4%) survived (Specificity = 99.1%, 95% CI: 97.4% to 99.8%, Sensitivity = 46.5%; 95% CI: 44.1% to 48.8%). The transportation rate was 60.7%, which was lower than for existing guidelines when applied to the same dataset. Of 656 patients in Phase 3, the guideline recommended termination of 162 patients. None of these survived to hospital discharge (Specificity = 100%, 95% CI: 95.6% to 100%, sensitivity = 29.3%, 95% CI: 25.6% to 33.4%). The transportation rate during this phase was 75.3%. When plotted on a ROC space, the guideline showed better predictive power, when compared to existing guidelines. The minimum cost saving was shown to be £33,739 per 1000 adult OHCA patients currently transported to hospital.

Conclusion:
Introducing the decision rule to the trust in question would reduce the number of transportations to hospital of adult patients suffering cardiac arrest of presumed cardiac aetiology. Further research is needed to apply the findings to other locations or emergency medical systems. In order to strengthen the validity of the tool, it should be assessed prospectively in either one large prospective study or several smaller studies, but within different settings. Ideally, to prevent bias, such a validation would be performed by a different research group.

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