title: Field termination of resuscitation: analysis of a newly implemented protocol.
abstract: BACKGROUND
  Earlier work has shown the safety of termination-of-resuscitation (TOR) protocols for traumatic and nontraumatic 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 and hospital records. EMS and ED records were evaluated to assess for the presence of TOR protocol criteria and to 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, and all 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, and all 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.
authors.affiliation: Emergency Medicine Residency Program, New Haven, Connecticut, USA. eaobrien76@comcast.net
authors.forename: Elizabeth
authors.initials: E
authors.lastname: O'Brien
authors.forename: David
authors.initials: D
authors.lastname: Hendricks
authors.forename: David C
authors.initials: DC
authors.lastname: Cone
mesh_terms: D000328:Adult; D003237:Connecticut; D004632:Emergency Medical Services / Q000592:standards / Q000706:statistics & numerical data*; D005260:Female; D006323:Heart Arrest / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D006801:Humans; D008297:Male; D018447:Medical Futility; D008875:Middle Aged; D012151:Resuscitation / Q000592:standards / Q000706:statistics & numerical data*; D014187:Transportation of Patients / Q000706:statistics & numerical data*; D028761:Withholding Treatment / Q000592:standards*