Field Termination of Resuscitation: Analysis of a Newly Implemented Protocol

Abstract

Introduction. Earlier work has shown the safety of termination-of-resuscitation (TOR) protocols for traumatic andnontraumatic out-of-hospital cardiac arrest (OOHCA). This study examined the implementation of these protocols in one urban/suburban EMS system. The objective was to determine how often patients are transported to the ED despite meeting TOR criteria. Methods. All adult OOHCA patients transported to two EDs during a 3.5-year interval were retrospectively identified through dispatch andhospital records. EMS andED records were evaluated to assess for the presence of TOR protocol criteria andto determine whether the patients should have been transported or pronounced dead on scene. Records were also examined for documentation of mitigating circumstances that might have prompted transport despite meeting TOR criteria. Results. 865 OOHCA patients were identified; 235 met study criteria. Of these, 131 (56%) met TOR criteria but were transported anyway. All expired in the ED or in the hospital (131/131 = 100%, 95% CI: 97.7–100) Of the 43 traumatic OOHCA patients, 27 (63%) met TOR criteria, yet were transported, andall expired in the ED (27/27 = 100%, 95% CI: 89.5–100). Of the 192 nontraumatic OOHCA patients, 104 (54%) met TOR criteria, yet were transported, andall expired in the ED or in the hospital (104/104 = 100%, 95% CI: 97.2–100). In no case was a mitigating circumstance documented to justify transporting a patient meeting TOR criteria. Conclusions. Termination-of-resuscitation protocols are not being implemented as intended in this EMS system: more than half of cardiac arrest patients meeting criteria for termination of resuscitation were transported anyway. These protocol violations result in emergency transport to the ED for a substantial number of patients for whom continued resuscitative efforts are futile: no patient who met TOR criteria in this sample survived to discharge.