Developing Quality Indicators for the Appropriateness of Resuscitation in Prehospital Atraumatic Cardiac Arrest

Abstract

Objective. The vast majority of out-of-hospital cardiac arrest victims do not survive or suffer severe neurological impairment. We sought to develop a set of straightforward clinical indicators that paramedics could use to better match resuscitation attempts to those most likely to benefit. Methods. In partnership with the Los Angeles County Emergency Medical Services, we used the RAND/UCLA appropriateness method of quantifying expert opinion regarding the risks andbenefits of medical procedures. We presented available scientific evidence related to potential indicators of the quality of resuscitative care to stakeholder-nominated experts. Forty-one candidate indicators incorporated key variables, including initial rhythm, patient preferences, presence of witnesses, andplace of arrest. Nine panelists, including palliative care andemergency medical specialists, rated the appropriateness of paramedic use of each indicator by using a 1–9 scale. An indicator was considered appropriate if the potential benefits outweighed the potential harm to the patient or their family. Indicators were retained if median score was ≥7. Results. The expert panel voted to retain 28 quality indicators. Three addressed signs of irreversible death (e.g., dependent lividity), 8 addressed patient preferences (e.g., inquiring about DNR status), andthe remainder addressed combinations of initial rhythm andother prognostic signs (e.g., “If initial rhythm is asystole andpatient is known by apparent surrogate decision maker to have a terminal illness, then forgo resuscitation.”). Our experts recommended a series of much more liberal criteria for forgoing resuscitation than is currently practiced. This includes ascertaining andhonoring patient preferences, either through written documents or family members, andcombinations of clinical criteria that predict poor neurological outcome, such as asystole, terminal illness, age greater than 70, andresponse time greater than 15 minutes. Conclusions. These quality indicators expand on the previously limited circumstances in which paramedics might forgo field resuscitation andimplementation could reduce future harm from such procedures among seriously ill patients. Our current efforts focus on using these indicators to aid implementation of a new resuscitation policy for seriously ill patients in our county.

Key words:

• preshospital care
• emergency medical services
• cardiopulmonary resuscitation
• ethics
• cardiac arrest