External validation of rules for termination of resuscitation in in-hospital cardiac arrest

Termination of resuscitation rules aim to avoid prolonged, futile resuscitative efforts, reducing patient and provider burden. To date, however, no widely adopted rule exists for termination of in-hospital cardiac arrest. A recent study derived a termination rule (unwitnessed, unmonitored, asystole, and no return of spontaneous circulation within 10 min) in a Scandinavian cohort with an acceptably high positive rate for clinical utility and a very low rate of patients meeting the rule who survived to 30-days.

To externally validate previously derived termination of resuscitation rules for patients suffering in-hospital cardiac arrest.

Observational study of a prospectively collected in-hospital cardiac arrest cohort including years 2012-2024.

Participating hospitals from the American Heart Association Get With The Guidelines-Resuscitation registry.

Adult patients (≥18 years) who suffered in-hospital cardiac arrest.

Meeting a previously described termination of resuscitation rule.

Survival to hospital discharge. Positive rates, false positive rates, false discovery rates, and resuscitation time potentially avoided were calculated. Hypothesis formulated prior to analysis.

Of 646,794 patients, 359,686 met inclusion criteria across 703 hospitals. Overall survival to discharge was 23.1%. For the primary Scandinavian termination Rule 1, the positive rate (patients meeting Rule criteria) was 1.7%; 32.9% of whom achieved return of spontaneous circulation and 5.1% survived to discharge. Median resuscitation time potentially avoided was 11 min per patient meeting Rule 1 criteria, equating to ∼18 min per 100 events. Across hospitals, positive rates ranged from 0% to 11.9. Other termination rules demonstrated either very low average positive rates (<3%) or unacceptably high survival rates among patients meeting the rule. Findings were similar in sensitivity analyses excluding the COVID-19 era.

In this large American cohort, previously derived termination rules for in-hospital cardiac arrest demonstrated either limited applicability or unacceptable error rates. Even the best-performing Scandinavian rule identified few patients for early termination and would have led to premature cessation in ∼5% of survivors. These findings underscore the need for further refinement of termination rules before clinical adoption in the United States.