title: Termination of Resuscitation Rules to Predict Neurological Outcomes in Out-of-Hospital Cardiac Arrest for an Intermediate Life Support Prehospital System.
abstract: Futile resuscitation can lead to unnecessary transports for out-of-hospital cardiac arrest (OHCA). The Basic Life Support (BLS) and Advanced Life Support (ALS) termination of resuscitation (TOR) guidelines have been validated with good results in North America. This study aims to evaluate the performance of these two rules in predicting neurological outcomes of OHCA patients in Singapore, which has an intermediate life support Emergency Medical Services (EMS) system.
  
  
  
  A retrospective cohort study was carried out on Singapore OHCA data collected from April 2010 to May 2012 for the Pan-Asian Resuscitation Outcomes Study (PAROS). The outcomes of each rule were compared to the actual neurological outcomes of the patients. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and predicted transport rates of each test were evaluated.
  
  
  
  A total of 2,193 patients had cardiac arrest of presumed cardiac etiology. TOR was recommended for 1,411 patients with the BLS-TOR rule, with a specificity of 100% (91.9, 100.0) for predicting poor neurological outcomes, PPV 100% (99.7, 100.0), sensitivity 65.7% (63.6, 67.7), NPV 5.6% (4.1, 7.5), and transportation rate 35.6%. Using the ALS-TOR rule, TOR was recommended for 587 patients, specificity 100% (91.9, 100.0) for predicting poor neurological outcomes, PPV 100% (99.4, 100.0), sensitivity 27.3% (25.4, 29.3), NPV 2.7% (2.0, 3.7), and transportation rate 73.2%. BLS-TOR predicted survival (any neurological outcome) with specificity 93.4% (95% CI 85.3, 97.8) versus ALS-TOR 98.7% (95% CI 92.9, 99.8).
  
  
  
  Both the BLS and ALS-TOR rules had high specificities and PPV values in predicting neurological outcomes, the BLS-TOR rule had a lower predicted transport rate while the ALS-TOR rule was more accurate in predicting futility of resuscitation. Further research into unique local cultural issues would be useful to evaluate the feasibility of any system-wide implementation of TOR.
authors.forename: Randy Wang Long
authors.initials: RW
authors.lastname: Cheong
authors.forename: Huihua
authors.initials: H
authors.lastname: Li
authors.forename: Nausheen Edwin
authors.initials: NE
authors.lastname: Doctor
authors.forename: Yih Yng
authors.initials: YY
authors.lastname: Ng
authors.forename: E Shaun
authors.initials: ES
authors.lastname: Goh
authors.forename: Benjamin Sieu-Hon
authors.initials: BS
authors.lastname: Leong
authors.forename: Han Nee
authors.initials: HN
authors.lastname: Gan
authors.forename: David
authors.initials: D
authors.lastname: Foo
authors.forename: Lai Peng
authors.initials: LP
authors.lastname: Tham
authors.forename: Rabind
authors.initials: R
authors.lastname: Charles
authors.forename: Marcus Eng Hock
authors.initials: ME
authors.lastname: Ong
mesh_terms: D000368:Aged; D016887:Cardiopulmonary Resuscitation / Q000706:statistics & numerical data*; D015331:Cohort Studies; D003661:Decision Support Techniques; D004632:Emergency Medical Services / Q000592:standards; D005260:Female; D006801:Humans; D008021:Life Support Systems / Q000706:statistics & numerical data*; D008297:Male; D058687:Out-of-Hospital Cardiac Arrest / Q000401:mortality / Q000628:therapy*; D017063:Outcome Assessment, Health Care; D011237:Predictive Value of Tests; D016414:Resuscitation Orders; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012846:Singapore; D015996:Survival Rate
keywords: cardiac arrest; neurological outcome; prehospital; termination of resuscitation