A hypothetical implementation of 'Termination of Resuscitation' protocol for out-of-hospital cardiac arrest.



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.


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.


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.


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.





Published Version (Please cite this version)


Publication Info

Nazeha, Nuraini, Marcus Eng Hock Ong, Alexander T Limkakeng, Jinny J Ye, Anjni Patel Joiner, Audrey Blewer, Nur Shahidah, Gayathri Devi Nadarajan, et al. (2021). A hypothetical implementation of 'Termination of Resuscitation' protocol for out-of-hospital cardiac arrest. Resuscitation plus, 6. p. 100092. 10.1016/j.resplu.2021.100092 Retrieved from https://hdl.handle.net/10161/23880.

This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.



Alexander Tan Limkakeng

Professor of Emergency Medicine

Dr. Alexander T. Limkakeng, Jr., MD, MHSc, FACEP is a Professor of Emergency Medicine, Vice Chair of Clinical Research, Director of the Acute Care Research Team, and Director of the Resident Research Fellowship for the Department of Emergency Medicine in the Duke University School of Medicine in Durham, North Carolina.

Dr. Limkakeng has served as chair of the American College of Emergency Physicians (ACEP) Research Committee, and been the Course Director of the ACEP Research Forum from 2016-2018, the largest emergency medical research platform in the nation. He is also the Assistant Director of ACEP’s Emergency Medicine Basic Research Skills course. He was elected to the Nominating Committee of the Society of Academic Emergency Medicine.

As a researcher, Dr. Limkakeng has led multiple clinical trials and interdepartmental sponsored projects and is author on over 100 peer-reviewed manuscripts. These include studies in emergency conditions such as COVID-19, traumatic brain injury, hypertension, heart failure, thrombosis, stroke, envenomations, and septic shock. His research has been funded by grants and contracts totaling over $9 million dollars. He has lectured internationally on acute coronary syndrome, responsible conduct of research, design of clinical trials, and precision medicine in emergency care. He has led Duke’s involvement in NIH-funded research networks and in industry-funded work that led to FDA approval for multiple high-sensitivity cardiac troponin assays and point-of-care COVID-19 diagnostic tests. He has servesd as Co-PI for the Duke U24 Hub in the NIH Early Phase Pain Investigation Clinical Network (EPPIC-Net) (1U24NS114416) and now serves as a co-PI on the Duke U24 Hub award (1U24NS129498) in the NIH Strategies to Innovate Emergency Care Clinical Trials (SIREN) Network and in the NIH NINDS Strokenet network (1U24NS135250)

His personal research interest is finding new ways to diagnose acute coronary syndrome. In particular, he is interested in novel biomarkers and precision medicine approaches to this problem. The common element throughout this work is a focus on time-sensitive health conditions.

Anjni Patel Joiner

Associate Professor of Emergency Medicine

Anjni Joiner, DO, MPH, FACEP, FAEMS is an Assistant Professor of Emergency Medicine at Duke University School of Medicine. Dr. Joiner serves as Medical Director of Prehospital Medicine at Duke University Hospital, overseeing the Emergency Medical Services section within the Department of Emergency Medicine. She also serves as the Medical Director for Durham County EMS, providing medical oversight to all county agencies, including EMS, first responders, and the Durham Emergency Call Center. In these roles, she strives to work collaboratively with community partners to provide care to underserved and underrepresented populations. These efforts include development of Community Paramedicine programs to address opioid use disorder in Durham Community through harm reduction techniques and partnering with organizations such as the City of Durham HEART team for unarmed police response.

Her research interests include injury prevention and trauma, development and strengthening of prehospital emergency care systems internationally, and improving access to care. Her current projects include a comprehensive assessment of the emergency care system in Moshi, Tanzania through a community needs and hospital capacity assessment and development of a prehospital emergency care system evaluation tool (PECSET) for underdeveloped EMS systems in South and Southeast Asia.


Audrey L Blewer

Assistant Professor in Family Medicine and Community Health

Audrey L. Blewer, PhD, MPH is an epidemiologist and resuscitation scientist in the Department of Family Medicine and Community Health and Department of Population Health Sciences within Duke University School of Medicine. Dr. Blewer completed her Doctor of Philosophy in Epidemiology at the University of Pennsylvania from the Department of Biostatistics, Epidemiology, and Informatics and her Master of Public Health in Social in Behavioral Sciences from the University of Florida.

Dr. Blewer has published in several noteworthy journals such as Circulation, Lancet Public Health, Circulation Cardiovascular Quality and Outcomes, and Critical Care Medicine. She is recognized in the field of resuscitation science nationally and internationally. Dr. Blewer is contributing to the upcoming American Heart Association Guidelines writing group for Resuscitation Education and serves on the Editorial Board for the journal Resuscitation Plus. Dr. Blewer works on interdisciplinary research projects at both Duke and Duke-NUS Medical Center

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