A hypothetical implementation of ‘Termination of Resuscitation’ protocol for out-of-hospital cardiac arrest

Nuraini Nazeha, Marcus Eng Hock Ong, Alexander T. Limkakeng, Jinny J. Ye, Anjni Patel Joiner, Audrey Blewer, Nur Shahidah, Gayathri Devi Nadarajan, Desmond Renhao Mao, Nicholas Graves*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Background: Out-of-hospital cardiac arrests with negligible chance of survival are routinely transported to hospital and many are pronounced dead thereafter. This leads to some potentially avoidable costs. The ‘Termination of Resuscitation’ protocol allows paramedics to terminate resuscitation efforts onsite for medically futile cases. This study estimates the changes in frequency of costly events that might occur when the protocol is applied to out-of-hospital cardiac arrests, as compared to existing practice. Methods: We used Singapore data from the Pan-Asian Resuscitation Outcomes Study, from 1 Jan 2014 to 31 Dec 2017. A Markov model was developed to summarise the events that would occur in two scenarios, existing practice and the implementation of a Termination of Resuscitation protocol. The model was evaluated for 10,000 hypothetical patients with a cycle duration of 30 days after having a cardiac arrest. Probabilistic sensitivity analysis accounted for uncertainties in the outcomes: number of urgent transports and emergency treatments, inpatient bed days, and total number of deaths. Results: For every 10,000 patients, existing practice resulted in 1118 (95% Uncertainty Interval 1117 to 1119) additional urgent transports to hospital and subsequent emergency treatments. There were 93 (95% Uncertainty Interval 66 to 120) extra inpatient bed days used, and 3 fewer deaths (95% Uncertainty Interval 2 to 4) in comparison to using the protocol. Conclusion: The findings provide some evidence for adopting the Termination of Resuscitation protocol. This policy could lead to a reduction in costs and non-beneficial hospital admissions, however there may be a small increase in the number of avoidable deaths.

Original languageEnglish
Article number100092
JournalResuscitation Plus
StatePublished - Jun 2021
Externally publishedYes


  • Emergency medical services
  • Markov model
  • Out-of-hospital cardiac arrest
  • Termination of Resuscitation


Dive into the research topics of 'A hypothetical implementation of ‘Termination of Resuscitation’ protocol for out-of-hospital cardiac arrest'. Together they form a unique fingerprint.

Cite this