title: A comparison of the universal TOR Guideline to the absence of prehospital ROSC and duration of resuscitation in predicting futility from out-of-hospital cardiac arrest.
abstract: The Universal Termination of Resuscitation (TOR) Guideline accurately identifies potential out-of-hospital cardiac arrest (OHCA) survivors. However, implementation is inconsistent with some Emergency Medical Service (EMS) agencies using absence of return of spontaneous circulation (ROSC) as sole criterion for termination.
  
  
  
  To compare the performance of the Universal TOR Guideline with the single criterion of no prehospital ROSC. Second, to determine factors associated with survival for patients transported without a ROSC. Lastly, to compare the impact of time to ROSC as a marker of futility to the Universal TOR Guideline.
  
  
  
  Retrospective, observational cohort study.
  
  
  
  Non-traumatic, adult (≥18 years) OHCA patients of presumed cardiac etiology treated by EMS providers.
  
  
  
  ROC-PRIMED and ROC-Epistry post ROC-PRIMED databases between 2007 and 2011.
  
  
  
  Primary outcome was survival to hospital discharge and the secondary outcome was functional survival. We used multivariable regression to evaluate factors associated with survival in patients transported without a ROSC.
  
  
  
  36,543 treated OHCAs occurred of which 9467 (26%) were transported to hospital without a ROSC. Patients transported without a ROSC who met the Universal TOR Guideline for transport had a survival of 3.0% (95% CI 2.5-3.4%) compared to 0.7% (95% CI 0.4-0.9%) in patients who met the Universal TOR Guideline for termination. The Universal TOR Guideline identified 99% of survivors requiring continued resuscitation and transportation to hospital including early identification of survivors who sustained a ROSC after extended durations of CPR.
  
  
  
  Using absence of ROSC as a sole predictor of futility misses potential survivors. The Universal TOR Guideline remains a strong predictor of survival.
authors.affiliation: Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, 30 Bond St. Toronto, Ontario M5B 1W8, Canada. Electronic address: DrennanI@smh.ca.
authors.forename: Ian R
authors.initials: IR
authors.lastname: Drennan
authors.affiliation: Clinical Trial Center, University of Washington Department of Biostatistics, Seattle, WA 98103, United States. Electronic address: ecase@uw.edu.
authors.forename: Erin
authors.initials: E
authors.lastname: Case
authors.affiliation: Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. Electronic address: richard.verbeek@sunnybrook.ca.
authors.forename: P Richard
authors.initials: PR
authors.lastname: Verbeek
authors.affiliation: Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, United States. Electronic address: Reyno406@msu.edu.
authors.forename: Joshua C
authors.initials: JC
authors.lastname: Reynolds
authors.affiliation: University of Washington School of Medicine, Department of Internal Medicine, Division of Cardiology, Harborview Medical Center, Seattle, WA, United States. Electronic address: zgoldber@uw.edu.
authors.forename: Zachary D
authors.initials: ZD
authors.lastname: Goldberger
authors.affiliation: Resuscitation Research Centre, Department of Emergency Medicine, Medical College of Wisconsin, WI, United States. Electronic address: jjasti@mcw.edu.
authors.forename: Jamie
authors.initials: J
authors.lastname: Jasti
authors.affiliation: Tualatin Valley Fire and Rescue, OR, United States. Electronic address: Mark.Charleston@tvfr.com.
authors.forename: Mark
authors.initials: M
authors.lastname: Charleston
authors.affiliation: ROC Clinical Trial Center, University of Washington, Seattle, WA, United States. Electronic address: hherren@uw.edu.
authors.forename: Heather
authors.initials: H
authors.lastname: Herren
authors.affiliation: Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, United States. Electronic address: aidris@sbcglobal.net.
authors.forename: Ahamed H
authors.initials: AH
authors.lastname: Idris
authors.affiliation: British Columbia Emergency Health Services, British Columbia, Canada. Electronic address: Paul.Leslie@bcehs.ca.
authors.forename: Paul R
authors.initials: PR
authors.lastname: Leslie
authors.affiliation: The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada. Electronic address: Maustin@toh.on.ca.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Austin
authors.affiliation: Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, United States. Electronic address: Way1111@126.com.
authors.forename: Yan
authors.initials: Y
authors.lastname: Xiong
authors.affiliation: Clinical Trial Center, University of Washington Department of Biostatistics, Seattle, WA 98103, United States. Electronic address: rschmick@uw.edu.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Schmicker
authors.affiliation: Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Division of Emergency Medicine, Department of Medicine, University of Toronto, Ontario, Canada. Electronic address: morrisonl@smh.ca.
authors.forename: Laurie J
authors.initials: LJ
authors.lastname: Morrison
mesh_terms: D000368:Aged; D016887:Cardiopulmonary Resuscitation / Q000592:standards*; D004632:Emergency Medical Services / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D058687:Out-of-Hospital Cardiac Arrest / Q000601:surgery / Q000628:therapy*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies
keywords: Cardiopulmonary resuscitation; Emergency Medical Services; Heart arrest