title: Implementation trial of the basic life support termination of resuscitation rule: reducing the transport of futile out-of-hospital cardiac arrests.
abstract: BACKGROUND
  The basic life support (BLS) termination of resuscitation (TOR) rule recommends transport and continued resuscitation when cardiac arrest is witnessed by EMT-Ds, or there is a return of spontaneous circulation, or a shock is given, and prior studies have suggested the transport rate should fall to 37%.
  
  
  RESULTS
  This real-time prospective multi-center implementation trial evaluated the BLS TOR rule for compliance, transport rate and provider and physician comfort. Both provider and physician noted their decision-making rationale and ranked their comfort on a 5-point Likert scale. Functional survival was measured at discharge. Of 2421 cardiac arrests, 953 patients were eligible for the rule, which was applied correctly for 755 patients (79%) of which 388 were terminated. 565 patients were transported resulting in a reduction of the transport rate from 100% (historical control) to 59% (p<0.001). The BLS TOR rule was not followed in 198 eligible patients (21%) and they were all transported despite meeting the criteria to terminate. Providers cited 241 reasons for non-compliance: family distress, short transport time interval, younger age and public venue. All 198 transported patients, non-compliant with the rule, died. Both providers and physicians were comfortable with using the rule to guide TOR (median [IQR] of 5 [4,5]; p<0.001).
  
  
  CONCLUSIONS
  This implementation trial confirmed the accuracy of the BLS TOR rule in identifying futile out-of-hospital cardiac arrest (OHCA) resuscitations, significantly reduced the transport rate of futile OHCA and most providers and physicians were comfortable following the rule's recommendations.
authors.affiliation: Rescu, Keenan Research Centre, Li Ka Shing Knowledge Institute at St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Division of Emergency, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Electronic address: MorrisonL@smh.ca.
authors.forename: Laurie J
authors.initials: LJ
authors.lastname: Morrison
authors.affiliation: Southwest Ontario Regional Base Hospital Program, London Health Sciences Centre, Owen Sound Site, Ontario, Canada; Division of Emergency, Department of Medicine, Western University, London, Ontario, Canada.
authors.forename: Don
authors.initials: D
authors.lastname: Eby
authors.affiliation: Rescu, Keenan Research Centre, Li Ka Shing Knowledge Institute at St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Precilla V
authors.initials: PV
authors.lastname: Veigas
authors.affiliation: Rescu, Keenan Research Centre, Li Ka Shing Knowledge Institute at St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Cathy
authors.initials: C
authors.lastname: Zhan
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Research Design & Biostatistics, Sunnybrook Health Sciences Centre, Institute for Clinical and Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Alex
authors.initials: A
authors.lastname: Kiss
authors.affiliation: Peterborough Regional Health Centre, Peterborough, Ontario, Canada.
authors.forename: Vince
authors.initials: V
authors.lastname: Arcieri
authors.affiliation: Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Paul
authors.initials: P
authors.lastname: Hoogeveen
authors.affiliation: Northeastern Ontario Prehospital Care Program, Health Sciences North, Timmins Site, Ontario, Canada.
authors.forename: Chris
authors.initials: C
authors.lastname: Loreto
authors.affiliation: Centre for Paramedic Education and Research, Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Michelle
authors.initials: M
authors.lastname: Welsford
authors.affiliation: Centre for Paramedic Education and Research, Hamilton Health Sciences Centre, Hamilton, Ontario, Canada.
authors.forename: Tim
authors.initials: T
authors.lastname: Dodd
authors.affiliation: Northeastern Ontario Prehospital Care Program, Health Sciences North, Sault Ste. Marie Site, Ontario, Canada.
authors.forename: Elma
authors.initials: E
authors.lastname: Mooney
authors.affiliation: Northeastern Ontario Prehospital Care Program, Health Sciences North, Timmins Site, Ontario, Canada.
authors.forename: Marty
authors.initials: M
authors.lastname: Pilkington
authors.affiliation: Southwest Ontario Regional Base Hospital Program, London Health Sciences Centre, Owen Sound Site, Ontario, Canada.
authors.forename: Cathy
authors.initials: C
authors.lastname: Prowd
authors.affiliation: Regional Paramedic Program for Eastern Ontario, Ottawa, Ontario, Canada.
authors.forename: Erica
authors.initials: E
authors.lastname: Reichl
authors.affiliation: Northeastern Ontario Prehospital Care Program, Health Sciences North, Sault Ste. Marie Site, Ontario, Canada.
authors.forename: Jim
authors.initials: J
authors.lastname: Scott
authors.affiliation: Regional Paramedic Program for Eastern Ontario, Ottawa, Ontario, Canada.
authors.forename: Jeanette M
authors.initials: JM
authors.lastname: Verdon
authors.affiliation: Medavie EMS Ontario (MEMSO Muskoka), Muskoka, Ontario, Canada.
authors.forename: Tim
authors.initials: T
authors.lastname: Waite
authors.affiliation: Rescu, Keenan Research Centre, Li Ka Shing Knowledge Institute at St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Jason E
authors.initials: JE
authors.lastname: Buick
authors.affiliation: Rescu, Keenan Research Centre, Li Ka Shing Knowledge Institute at St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Division of Emergency, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
authors.forename: P Richard
authors.initials: PR
authors.lastname: Verbeek
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D016887:Cardiopulmonary Resuscitation; D002985:Clinical Protocols; D003661:Decision Support Techniques; D004634:Emergency Medical Technicians / Q000523:psychology; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008020:Life Support Care; D008297:Male; D018447:Medical Futility; D008875:Middle Aged; D058687:Out-of-Hospital Cardiac Arrest / Q000401:mortality / Q000628:therapy*; D018579:Patient Selection; D010820:Physicians / Q000523:psychology; D011446:Prospective Studies; D016414:Resuscitation Orders; D014187:Transportation of Patients / Q000706:statistics & numerical data*
keywords: Cardiac arrest; Cardiopulmonary resuscitation; Emergency medical services