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Original Articles

A Qualitative Study to Identify Barriers to Local Implementation of Prehospital Termination of Resuscitation Protocols

Comilla Sasson, MD, MS; Jane Forman, ScD, MHS; David Krass, BA; Michelle Macy, MD, MS; Arthur L. Kellermann, MD, MPH and Bryan F. McNally, MD, MPH

From the Department of Emergency Medicine (C.S., D.K., M.M.), University of Michigan, and the Veterans Affairs Center for Clinical Management and Research (J.F.), Ann Arbor, Mich; and the Department of Emergency Medicine (A.L.K., B.F.M.), Emory University, Atlanta, Ga.

Correspondence to Comilla Sasson, MD, MS, Robert Wood Johnson Clinical Scholars Program, 1150 W Medical Center Drive, 6312 Medical Science Building 1, Campus Box 5604, Ann Arbor, MI 48109. E-mail comilla{at}umich.edu

Received November 15, 2008; accepted May 6, 2009.

Background— Despite the existence of national American Heart Association guidelines and 2 termination-of-resuscitation (TOR) rules for ceasing efforts in refractory out-of-hospital cardiac arrest, many emergency medical services agencies in the United States have adopted their own local protocols. Public policies and local perceptions may serve as barriers or facilitators to implementing national TOR guidelines at the local level.

Methods and Results— Three focus groups, lasting 90 to 120 minutes, were conducted at the National Association of Emergency Medical Services Physicians meeting in January 2008. Snowball sampling was used to recruit participants. Two reviewers analyzed the data in an iterative process to identify recurrent and unifying themes. We identified 3 distinct groups whose current policies or perceptions may 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 orders; and communities where cultural norms are perceived to impede termination of resuscitation. Our participants suggested that national organizations, such as the American Heart Association and American College of Emergency Physicians, may serve as potential facilitators in addressing these barriers by taking the lead in asking payers to change reimbursement structures; encouraging legislators to revise laws to reflect the best available medical evidence; and educating the public that rapid transport to the hospital cannot substitute for optimal provision of prehospital care.

Conclusion— We have identified 3 influential groups who will need to work with national organizations to overcome current policies or prevailing perceptions that may impede implementing national TOR guidelines.

Key Words: heart arrest • death, sudden

Presented at the American College of Emergency Physicians Meeting, October 2008.

The online-only Data Supplement is available at http://circoutcomes.ahajournals.org/cgi/content/full/10.1161/CIRCOUTCOMES.108.830398/DC1.

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