Original Investigation
Emergency Medicine
July 3, 2024
Termination of Resuscitation Rules and Survival Among Patients With Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis
Michael A. Smyth, Imogen Gunson, Alison Coppola, et al
JAMA Netw Open. 2024;7(7):e2420040. doi:10.1001/jamanetworkopen.2024.20040
Question Can termination of resuscitation (TOR) rules accurately identify patients who will not survive an out-of-hospital cardiac arrest?
Findings This systematic review and meta-analysis identified 43 studies describing the performance of TOR rules, but evidence concerning the ability of TOR rules to discriminate between those patients who will die and those who will survive was lacking. The available studies provided low-certainty evidence suggesting that the universal termination of resuscitation (UTOR) rule has the best performance; however, even the UTOR rule may not be suitable for use in systems in which transport rates are low and the survival rate is higher than 8%.
Meaning These findings suggest that there is insufficient robust evidence to support widespread implementation of TOR rules in clinical practice.
Abstract
Importance Termination of resuscitation (TOR) rules may help guide prehospital decisions to stop resuscitation, with potential effects on patient outcomes and health resource use. Rules with high sensitivity risk increasing inappropriate transport of nonsurvivors, while rules without excellent specificity risk missed survivors. Further examination of the performance of TOR rules in estimating survival of out-of-hospital cardiac arrest (OHCA) is needed.
Objective To determine whether TOR rules can accurately identify patients who will not survive an OHCA.
Data Sources For this systematic review and meta-analysis, the MEDLINE, Embase, CINAHL, Cochrane Library, and Web of Science databases were searched from database inception up to January 11, 2024. There were no restrictions on language, publication date, or time frame of the study.
Study Selection Two reviewers independently screened records, first by title and abstract and then by full text. Randomized clinical trials, case-control studies, cohort studies, cross-sectional studies, retrospective analyses, and modeling studies were included. Systematic reviews and meta-analyses were reviewed to identify primary studies. Studies predicting outcomes other than death, in-hospital studies, animal studies, and non–peer-reviewed studies were excluded.
Data Extraction and Synthesis Data were extracted by one reviewer and checked by a second. Two reviewers assessed risk of bias using the Revised Quality Assessment Tool for Diagnostic Accuracy Studies. Cochrane Screening and Diagnostic Tests Methods Group recommendations were followed when conducting a bivariate random-effects meta-analysis. This review followed the Preferred Reporting Items for a Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) statement and is registered with the International Prospective Register of Systematic Reviews (CRD42019131010).
Main Outcomes and Measures Sensitivity and specificity tables with 95% CIs and bivariate summary receiver operating characteristic (SROC) curves were produced. Estimates of effects at different prevalence levels were calculated. These estimates were used to evaluate the practical implications of TOR rule use at different prevalence levels.
Results This review included 43 nonrandomized studies published between 1993 and 2023, addressing 29 TOR rules and involving 1 125 587 cases. Fifteen studies reported the derivation of 20 TOR rules. Thirty-three studies reported external data validations of 17 TOR rules. Seven TOR rules had data to facilitate meta-analysis. One clinical study was identified. The universal termination of resuscitation rule had the best performance, with pooled sensitivity of 0.62 (95% CI, 0.54-0.71), pooled specificity of 0.88 (95% CI, 0.82-0.94), and a diagnostic odds ratio of 20.45 (95% CI, 13.15-31.83).
Conclusions and Relevance In this review, there was insufficient robust evidence to support widespread implementation of TOR rules in clinical practice. These findings suggest that adoption of TOR rules may lead to missed survivors and increased resource utilization.
