title: The Utstein template and the effect of in-hospital decisions: the impact of do-not-attempt resuscitation status on survival to discharge statistics.
abstract: BACKGROUND
  Variables for reporting outcome of pre-hospital cardiac arrest have been delineated in the Utstein style template. The primary outcome statistic is survival to hospital discharge (SHD). The template allows comparisons of pre-hospital care systems and has been used to determine the benefit of pre-hospital interventions. Post-resuscitation care has not been standardized and in-hospital events that affect SHD are not considered in the template.
  
  
  OBJECTIVE
  To determine the frequency and timing with which do-not-attempt resuscitation (DNAR) status is conferred following resuscitation from pre-hospital cardiac arrest and to assess the impact of this action on SHD.
  
  
  METHODS
  A 4-year retrospective, observational cohort study of all adult patients successfully resuscitated from nontraumatic pre-hospital cardiac arrest and admitted to a single municipal teaching hospital. Study variables included age, witnessed arrest, bystander cardiopulmonary resuscitation (CPR), initial rhythm documented by paramedics, hospital admission rate, frequency and time at which DNAR status was conferred, and SHD.
  
  
  RESULTS
  Four hundred and eighteen adult patients experienced pre-hospital arrest and received standard advanced cardiac life support interventions during the study period. Seventy-nine patients (19%; 95% confidence interval (CI), 15-23%) survived to be admitted to the hospital. Fifty-four of these patients (68%; 96% CI, 57-78%) were subsequently placed in DNAR status. Only one of these patients had a living will or advanced directive prior to cardiopulmonary arrest. In 37 DNAR patients (68%; 95% CI, 54-81%), DNAR status was conferred within 24 h of hospital admission. For patients made DNAR within 24 h of admission, 38% had a witnessed arrest, 22% had ventricular fibrillation as the first documented arrest rhythm, and 29% received bystander CPR. When patients made DNAR are included in the calculation of SHD rate, the SHD rate for the study period was 5.3% (95% CI, 3.3-7.8%). If DNAR patients are excluded, the SHD was 6.1% (95% CI, 3.8-9.0%), representing a 15% increase in SHD rate.
  
  
  CONCLUSIONS
  In-hospital care and medical decision making are not considered in the Utstein template and can have a significant effect on reported survival statistics. When assessing the benefit of pre-hospital interventions, it may be preferable to consider survival to hospital admission as the primary outcome statistic until such time as post-resuscitation care after hospital admission is rigidly standardized.
authors.affiliation: Department of Emergency Medicine, UCLA School of Medicine, Harbor-UCLA Medical Center, Box 21, 1000 West Carson Street, Torrance, CA 90509, USA. jniemann@emedharbor.edu
authors.forename: J T
authors.initials: JT
authors.lastname: Niemann
authors.forename: S J
authors.initials: SJ
authors.lastname: Stratton
mesh_terms: D000328:Adult; D022561:Advanced Cardiac Life Support; D015331:Cohort Studies; D006323:Heart Arrest / Q000401:mortality*; D006746:Hospital Bed Capacity, 500 and over; D006773:Hospitals, Municipal; D006801:Humans; D017063:Outcome Assessment, Health Care; D010351:Patient Discharge / Q000706:statistics & numerical data*; D016414:Resuscitation Orders; D012189:Retrospective Studies