title: Applicability of the prehospital termination of resuscitation rule in an area dense with hospitals in Tokyo: a single-center, retrospective, observational study: is the pre hospital TOR rule applicable in Tokyo?
abstract: BACKGROUND
  It is unclear whether the prehospital termination of resuscitation (TOR) rule is applicable in specific situations such as in areas extremely dense with hospitals.
  
  
  OBJECTIVE
  The objective of the study is to assess whether the prehospital TOR rule is applicable in the emergency medical services system in Japan, specifically, in an area dense with hospitals in Tokyo.
  
  
  METHODS
  This study was a retrospective, observational analysis of a cohort of adult out-of-hospital cardiopulmonary arrest (OHCA) patients who were transported to the University of Tokyo Hospital from April 1, 2009, to March 31, 2011.
  
  
  RESULTS
  During the study period, 189 adult OHCA patients were enrolled. Of the 189 patients, 108 patients met the prehospital TOR rule. The outcomes were significantly worse in the prehospital TOR rule-positive group than in the prehospital TOR-negative group, with 0.9% vs 11.1% of patients, respectively, surviving until discharge (relative risk [RR], 1.11; 95% confidence interval [CI], 1.03-1.21; P = .0020) and 0.0% vs 7.4% of patients, respectively, discharged with a favorable neurologic outcome (RR, 1.08; 95% CI, 1.02-1.15; P = .0040). The prehospital TOR rule had a positive predictive value (PPV) of 99.1% (95% CI, 96.3-99.8) and a specificity of 90.0% (95% CI, 60.5-98.2) for death and a PPV of 100.0% (95% CI, 97.9-100.0) and a specificity of 100.0% (95% CI, 61.7-100.0) for an unfavorable neurologic outcome.
  
  
  CONCLUSIONS
  This study suggested that the prehospital TOR rule predicted unfavorable outcomes even in an area dense with hospitals in Tokyo and might be helpful for identifying the OHCA patients for whom resuscitation efforts would be fruitless.
authors.affiliation: Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan. Electronic address: tatsumafukuda-jpn@umin.ac.jp.
authors.forename: Tatsuma
authors.initials: T
authors.lastname: Fukuda
authors.affiliation: Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan.
authors.forename: Naoko
authors.initials: N
authors.lastname: Ohashi
authors.affiliation: Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan.
authors.forename: Takehiro
authors.initials: T
authors.lastname: Matsubara
authors.affiliation: Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan.
authors.forename: Kent
authors.initials: K
authors.lastname: Doi
authors.affiliation: Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan.
authors.forename: Masataka
authors.initials: M
authors.lastname: Gunshin
authors.affiliation: Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Ishii
authors.affiliation: Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan.
authors.forename: Yoichi
authors.initials: Y
authors.lastname: Kitsuta
authors.affiliation: Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan.
authors.forename: Susumu
authors.initials: S
authors.lastname: Nakajima
authors.affiliation: Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan.
authors.forename: Naoki
authors.initials: N
authors.lastname: Yahagi
mesh_terms: D000368:Aged; D003661:Decision Support Techniques; D004632:Emergency Medical Services / Q000379:methods* / Q000592:standards; D005260:Female; D006801:Humans; D008297:Male; D058687:Out-of-Hospital Cardiac Arrest / Q000628:therapy*; D012151:Resuscitation; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D014041:Tokyo / Q000453:epidemiology; D028761:Withholding Treatment / Q000592:standards / Q000706:statistics & numerical data