title: A qualitative study to identify barriers to local implementation of prehospital termination of resuscitation protocols.
abstract: BACKGROUND
  Despite the existence of national American Heart Association guidelines and 2 termination-of-resuscitation (TOR) rules for ceasing efforts in refractory out-of-hospital cardiac arrest, many emergency medical services agencies in the United States have adopted their own local protocols. Public policies and local perceptions may serve as barriers or facilitators to implementing national TOR guidelines at the local level.
  
  
  RESULTS
  Three focus groups, lasting 90 to 120 minutes, were conducted at the National Association of Emergency Medical Services Physicians meeting in January 2008. Snowball sampling was used to recruit participants. Two reviewers analyzed the data in an iterative process to identify recurrent and unifying themes. We identified 3 distinct groups whose current policies or perceptions may impede efforts to adopt national TOR guidelines: payers who incentivize transport; legislators who create state mandates for transport and allow only narrow use of do-not-resuscitate orders; and communities where cultural norms are perceived to impede termination of resuscitation. Our participants suggested that national organizations, such as the American Heart Association and American College of Emergency Physicians, may serve as potential facilitators in addressing these barriers by taking the lead in asking payers to change reimbursement structures; encouraging legislators to revise laws to reflect the best available medical evidence; and educating the public that rapid transport to the hospital cannot substitute for optimal provision of prehospital care.
  
  
  CONCLUSIONS
  We have identified 3 influential groups who will need to work with national organizations to overcome current policies or prevailing perceptions that may impede implementing national TOR guidelines.
authors.affiliation: Department of Emergency Medicine, University of Michigan, Ann Arbor, Mich., USA. comilla@umich.edu
authors.forename: Comilla
authors.initials: C
authors.lastname: Sasson
authors.forename: Jane
authors.initials: J
authors.lastname: Forman
authors.forename: David
authors.initials: D
authors.lastname: Krass
authors.forename: Michelle
authors.initials: M
authors.lastname: Macy
authors.forename: Arthur L
authors.initials: AL
authors.lastname: Kellermann
authors.forename: Bryan F
authors.initials: BF
authors.lastname: McNally
mesh_terms: D016887:Cardiopulmonary Resuscitation / Q000592:standards*; D004632:Emergency Medical Services / Q000331:legislation & jurisprudence / Q000592:standards*; D004634:Emergency Medical Technicians / Q000592:standards; D004635:Emergency Medicine / Q000592:standards; D016529:Emergency Nursing / Q000592:standards; D017144:Focus Groups; D006291:Health Policy / Q000331:legislation & jurisprudence; D006323:Heart Arrest / Q000401:mortality* / Q000628:therapy*; D006801:Humans; D017410:Practice Guidelines as Topic; D036301:Qualitative Research; D014481:United States / Q000453:epidemiology; D028761:Withholding Treatment / Q000592:standards*