# Validation of the Termination of Resuscitation Rules in Detroit

## TL;DR

This study validates rules for deciding when to stop resuscitation during cardiac arrests in Detroit and suggests improvements to reduce unnecessary hospital transports.

## Contribution

The study validates and proposes improvements to termination of resuscitation (TOR) rules in Detroit using real-world data.

## Key findings

- The BLS TOR rule improved specificity and positive predictive value after implementation in Detroit.
- Adding EMS time or patient age to TOR criteria reduced false positive terminations and increased transportation rates.
- Survival to hospital discharge remained low, suggesting TOR rules help avoid futile resuscitation.

## Abstract

Background and objective

The termination of resuscitation (TOR) criteria - which recommends termination when a non-traumatic arrest in an adult is unwitnessed by emergency medical services (EMS), no shocks are administered, and no return of spontaneous circulation (ROSC) occurs - guide physicians in determining the viability of continuing cardiopulmonary resuscitation (CPR) and transporting patients to the hospital. We examined the level of compliance with the current basic life support (BLS) TOR rule and assessed alternative sets of rules to retrospectively derive improved TOR guidelines for out-of-hospital cardiac arrests (OHCA) in Detroit.

Methods

This was a retrospective study involving non-traumatic OHCA cases in Detroit from January 1, 2017, to December 31, 2019, which spans the time frame before and after the BLS TOR rule was officially implemented (June 1, 2018). Data were extracted from the Detroit Cardiac Arrest Registry (DCAR). Patients younger than 18 years of age, those with arrests of traumatic origin, or those with no resuscitation attempted were excluded.

Results

A total of 1,306 individuals were included in our analysis: 656 OHCA cases before the implementation of the BLS TOR rule in Detroit and 650 OHCA after the implementation. BLS TOR criteria were applied to the pre-TOR implementation data with a resulting specificity of 79% (95% CI: 50.7-80.8) and positive predictive value (PPV) of 97.3% (95% CI: 95.5-98.6). Survival to hospital discharge when termination was recommended was projected at 2.9% (13/444). The overall transportation rate was 85% (559/656). Post-TOR implementation, specificity was 88.9% (95% CI: 78.6-99.1) and PPV was 99.1% (95% CI: 98.3-99.9). Survival to hospital discharge was 0.88% (4/453) with a 69% (451/650) overall transportation rate. Post-hoc addition of age or EMS time to the patient side increased transportation rates to 81% (529/650) and 88% (571/650), respectively, and decreased false positive terminations to 0.84% (2/237) and 0% (0/148), respectively.

Conclusions

Overall survival and futile transportation rates decreased when TOR was applied since the implementation of the BLS TOR rule in Detroit. The addition of EMS time to the patient side or patient age to current TOR guidelines suggested improved performance. Although the additional criteria resulted in higher transportation rates, these factors may be useful for physicians to consider when deciding to transport patients. However, further derivation and validation are needed to create optimal TOR guidelines.