Abstract
Several clinical decision rules (CDRs) have been developed to help practitioners know when to safely terminate resuscitative efforts after in-hospital cardiac arrest (IHCA). The UN10 rule, a CDR that uses 3 intra-arrest variables, has been shown to predict a poor chance of survival to discharge. However, its large-scale applicability in clinical settings remains unknown. To assess the performance of a parsimonious CDR in a national cohort of individuals with IHCA. This retrospective cohort study used a nationwide cohort from the American Heart Association Get With the Guidelines-Resuscitation IHCA registry to derive a sample of 96 509 patients from 716 US hospitals who experienced IHCA from January 1, 2000, to January 26, 2016. Data analysis began in January 2018 and concluded in June 2018. The UN10 rule uses 3 variables: (1) unwitnessed arrest, (2) nonshockable rhythm, and (3) no return of spontaneous circulation within 10 minutes of resuscitative efforts. The CDR indicates futility if all 3 criteria are met. This CDR was analyzed according to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guideline. The primary outcome was survival to hospital discharge following resuscitation. Favorable neurologic status at discharge was also assessed. Overall rates of survival and survival with favorable neurologic status (cerebral performance category score, 1 or 2) were compared with predicted values by the UN10 rule using 2 × 2 contingency tables. Of 96 509 patients, 55 761 (57.8%) were men, and the mean (SD) age was 67.1 (15.3) years. In total, 18 713 patients (19.4%) survived to discharge, and 16 134 patients (16.7%) were discharged with a favorable neurologic status. Overall, 15 838 patients (16.4%) met all 3 criteria for futility in the UN10 rule. A total of 1005 patients (6.3%) who met the UN10 rule survived to discharge, and 754 (4.8%) survived with favorable neurologic status. The percentage of patients meeting the UN10 rule (ie, predicting futile resuscitation) who actually survived in our study cohort was substantially higher than the initial derivation cohort (0%) and single-center validation cohort (1.1%). The positive predictive value of the UN10 rule was 93.7% (95% CI, 93.3%-94.0%), which was lower than the initial derivation cohort (100%; 95% CI, 97.5%-100%) and validation cohort (98.9%; 95% CI, 96.5%-99.7%). Patients who met the UN10 rule were associated with unfavorable neurologic status and low rates of survival after IHCA. Yet their survival rates are higher than reported in the initial validation study, raising the question of whether the UN10 rule may have limited utility as a definitive measure of futility during resuscitations in real-world clinical settings.
Highlights
Several clinical decision rules (CDRs) have been developed to help practitioners avoid potentially futile resuscitative efforts in hospitalized patients.1-8 their overall utility is limited, primarily because of model complexity, inadequate validation, or insufficiently low positive predictive values.1-6 Van Walraven et al7,8 developed a parsimonious model incorporating 3 readily available intra-arrest variables, to identify patients with in-hospital cardiac arrest (IHCA) who have no chance of survival to discharge
The percentage of patients meeting the UN10 rule who survived in our study cohort was substantially higher than the initial derivation cohort (0%) and single-center validation cohort (1.1%)
The positive predictive value of the UN10 rule was 93.7%, which was lower than the initial derivation cohort (100%; 95% CI, 97.5%-100%) and validation cohort (98.9%; 95% CI, 96.5%99.7%)
Summary
Several clinical decision rules (CDRs) have been developed to help practitioners avoid potentially futile resuscitative efforts in hospitalized patients. their overall utility is limited, primarily because of model complexity, inadequate validation, or insufficiently low positive predictive values. Van Walraven et al developed a parsimonious model incorporating 3 readily available intra-arrest variables, to identify patients with in-hospital cardiac arrest (IHCA) who have no chance of survival to discharge. Van Walraven et al developed a parsimonious model incorporating 3 readily available intra-arrest variables, to identify patients with in-hospital cardiac arrest (IHCA) who have no chance of survival to discharge This model, which we call the UN10 rule based on the 3 variables (U, unwitnessed arrest; N, nonshockable rhythm; and 10, return of spontaneous circulation [ROSC] not obtained within 10 minutes), was prospectively validated in 2181 patients at a single hospital nearly 20 years ago. While it is unclear how widely used this model currently is in clinical settings, the application of a simple CDR relying on just 3 intra-arrest variables in code settings could greatly enhance termination decisions. How it performs in a broader sample of hospitalized patients and in the context of a diverse population and contemporary resuscitation care practices remains unknown
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