Performance of Universal TOR rule for out-of-hospital cardiac arrest in the Pan-Asian Resuscitation Outcomes Study

Aim

Out-of-hospital cardiac arrest (OHCA) is a public health problem. The Universal Termination of Resuscitation (TOR) rule attempts to reduce the rate of futile transports. The aim of this study was to examine and compare the performance of the TOR rule for OHCA cases in Japan, Korea, Singapore, and Taiwan, where the TOR rule has not been implemented.

Methods

This retrospective cohort study examined data from January 1, 2009, to June 30, 2018, reported to the Pan-Asian Resuscitation Outcomes Study. We included patients with nontraumatic OHCA in the four countries and compared the performance of the Universal TOR rule in these countries.

Results

The number of eligible cases was 173,629. The performance of the Universal TOR rule for cases of neurologically poor survival showed a positive predictive value of more than 0.99 in all four countries. However, specificity differed among them: Japan 0.938, 95% confidence interval (CI): 0.931–0.945; Korea 0.922, 95% CI: 0.901–0.939; Singapore 0.985, 95% CI: 0.964–0.993; and Taiwan 0.773, 95% CI: 0.736–0.807.

Conclusion

The positive predictive value of neurologically poor survival in cases meeting the Universal TOR rule among the four countries was greater than 99%. However, the specificity of these cases that met the Universal TOR rule differed among the four countries. Therefore, further refinement of the Universal TOR rule may be needed for local implementation. The quality of resuscitation in an out-of-hospital setting may also impact survival and neurological outcomes and needs to be considered in any implementation of TOR.