Overcoming barriers for adoption of standardized TOR protocols

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Local policies and public perception about termination of resuscitation (TOR) guidelines often hinder adoption and implementation of national consensus guidelines for dealing with refractory out-of-hospital cardiac arrest. Researchers from the University of Michigan in Ann Arbor and Emory University in Atlanta have identified four national organization that can help overcome local and lay-public resistance to more effective use of EMS personnel when dealing with unsuccessful treatment out-of-hospital cardiac arrest.

Comilla Sasson, MD, from the Robert Wood Johnson clinical scholars program at Michigan, and colleagues conducted three focus groups at the 2008 National Association of EMS Physicians (NAEMSP) meeting (Circ Cardiovasc Qual Outcomes 2009;2;361-368).

The participants identified three distinct groups whose current policies or perceptions impede efforts to adopt national TOR guidelines: payers who incentivize transport; legislators who create state mandates for transport and allow only narrow use of do-not-resuscitate (DNR) orders; and communities where cultural norms are perceived to impede TOR.

The focus group participants also identified four national organizations that may help overcome these barriers:
  • American Heart Association;
  • American College of Emergency Physicians;
  • National Highway Traffic Safety Association; and

On the national level, the organizations could work with legislators to change the legal and financial structures that currently favor ambulance transport over TOR; do not reimburse EMS systems for expensive new technological advancements such as AEDs; and have created highly variable DNR processes across states.

On a local level, EMS agencies and hospitals, with the support of national organizations, could be empowered to advocate for the removal of state mandates for the transport of cardiac arrest patients.

At the community level, these national organizations can continue to emphasize the importance of prompt activation of 911 and the provision of bystander CPR, while presenting realistic expectations of cardiac arrest survivability. Surveys have revealed that a majority of people believe at least half of all out-of-hospital cardiac arrest patients will survive. The reality is that one in 10 survives.

“The cardiovascular medical world will play an important role in all three of the areas we have identified in this study,” Sasson told Cardiovascular Business News via email. “The first and foremost way is by educating the American public about the realities of out-of-hospital cardiac arrest survival.”

Sasson also said that it is important for physicians and staff to discuss DNR/do-not-intubate (DNI) orders with patients and their families so that during a cardiac arrest, “we as medical professionals can provide the level of care the patient had wanted.”

The EMS system of Seattle has consistently reported the best out-of-hospital cardiac arrest survival rates in the country, according to the study. Bystander CPR rates are high, but EMS providers deliver early defibrillation and optimal advanced cardiac life support (ACLS) on-scene for up to 30 minutes in an effort to achieve return of spontaneous circulation (ROSC). If ROSC is not achieved in that timeframe, resuscitation efforts are ceased.

“Seattle’s approach recognizes that the best way to achieve resuscitation and long-term survival is through optimal delivery of resuscitation efforts on-scene, rather than delaying treatment to rush the patient to the nearest emergency department,” the authors wrote.

Researchers used Seattle’s experience to refute the apprehension by some physicians that policies that permit prehospital TOR may lead EMS providers to not try as hard as they otherwise would, creating a “self-fulfilling prophecy.” They said that Seattle’s experience belies this belief.

Sasson said she and others are working with the Centers for Medicare & Medicaid Services (CMS) and other insurers to help set up a payment system that is policy-neutral, “rather than penalizing EMS systems that practice the best resuscitation techniques by staying on-scene and transporting only those patients that meet criteria.”

Current Medicare reimbursement provides higher payments for the transport of patients to the emergency department as compared with ceasing resuscitation efforts in the out-of-hospital setting.

Sasson also would like to see a standardized DNR/DNI system, which would “greatly improve both prehospital and emergency care for patients.”

On the lay-public, she said it’s important to manage their expectations of survival from an out-of-hospital cardiac arrest.

The next leg of the research is focused on the operational issues that serve as barriers to local implementation of national EMS best practices, Sasson said.

“There is marked variability in the education and training of our nation's EMS providers, EMS medical directors and physicians who serve as medical control for our EMS providers,” she said. “Overcoming the overarching barriers to communication, standardized educational requirements and the coordination of local services will be an integral step in moving toward standardizing best practices for our nation's EMS systems.”