Abstract 258: Adherence to the Transport Recommendations in the Universal Termination of Resuscitation Rule and Survival After Out-of-Hospital Cardiac Arrest

Abstract

Introduction: Survival after out-of-hospital cardiac arrest (OHCA) varies across emergency medical services (EMS) systems. The contribution of EMS practices variation on the outcome disparities is unclear. We evaluated the association between EMS agency variation in adherence to the transport recommendations in the Universal Termination of Resuscitation (TOR) Rule and survival after OHCA. Methods: We conducted a secondary analysis of the Resuscitation Outcomes Consortium Epistry. We included adults (≥ 18 years) with OHCA for whom EMS providers attempted resuscitation from 2011 through 2015. The main exposure was the proportion of patients for whom the Universal TOR Rule recommended transport (i.e., meeting any one of the following criteria, EMS-witnessed arrest; return of spontaneous circulation prior to transport; or shock delivery prior to transport) among those transported to hospitals, at the level of EMS agency. We then categorized EMS agencies into quartiles. Our primary outcome was survival to hospital discharge. We used multilevel modified Poisson regression model, including patient-level and EMS-level covariates with patients nested within EMS agencies. Results: We included 42,584 EMS-treated OHCAs from 112 EMS agencies. The median proportion of patients for whom the TOR rule recommended transport among those transported was 88.2% (interquartile range [IQR] 76.1-96.7) across EMS agencies. Compared with the patients treated at EMS agencies in the quartile of the lowest proportion (the median proportion 66.7%[ IQR 50.9-71.7]), survival to hospital discharge was associated with treatment at EMS agencies in the second quartile (the median proportion 83.0% [IQR 79.8-85.3]) (adjusted risk ratio [aRR] 1.12, 95% confidence interval [CI] 0.96-1.31), the third quartile (the median proportion 93.0% [IQR 89.7-95.6]) (aRR 1.58, 95% CI 1.32-1.87), and the fourth quartile (the median proportion 100% [IQR 98.5-100]) (aRR 1.86, 95% CI 1.59-2.19). Conclusions: In this large cohort study of adult patients with OHCA, treatment at EMS agencies with higher proportion of patients who met transport criteria of the Universal TOR rule among transported patients was associated with survival to hospital discharge.