Title
Author
DOI
Article Type
Special Issue
Volume
Issue
Reasons for the termination of resuscitation in out-of-hospital cardiac arrests before and after the COVID-19 pandemic in Korea
1Department of Emergency Medicine, Kangdong Sacred Heart Hospital, 05355 Seoul, Republic of Korea
2Graduate School, Department of Biomedical Engineering, College of Medicine, Hanyang University, 04763 Seoul, Republic of Korea
*Corresponding Author(s):faith2love@kdh.or.kr (Youngsuk Cho)
† These authors contributed equally.
| History | Submitted: 02 October 2022 | Accepted: 09 November 2022 | Published: 08 May 2023 |
| Copyright: | ©2023 The Author(s). Published by MRE Press. |
The incidence of out-of-hospital cardiac arrest (OHCA) gradually increased during the coronavirus disease 2019 (COVID-19) pandemic, and the number of cases requiring termination of resuscitation (TOR) also rose. This study aimed to analyze the reasons for TOR of OHCA cases over 2 years (2019–2020). This retrospective observational study was conducted using data gathered from prehospital emergency medical service (EMS) care reports generated in Seoul between 01 January 2019, and 31 December 2020. We included OHCA cases reported to the EMS system in this study. Patients who experienced cardiac arrest for a non-medical cause and received cardiopulmonary resuscitation (CPR) from EMS paramedics at the scene were excluded. The variables of demographics and comorbidities, arrest location, identity of the bystander, cause of cardiac arrest, first monitored electrocardiographic (ECG) rhythm, and reason for TOR were investigated. We compared data for 1 year before and after the start of the COVID-19 pandemic. A total of 10,872 OHCAs with TOR were included in this study; of these, 6238 cardiac arrest cases were terminated without resuscitation attempts during the COVID-19 period compared to 4634 during the pre-COVID-19 period. During the COVID-19 period, the proportion of women in the total population decreased, while the median age increased (p < 0.001). Patients with comorbidities, the frequency of asystole rhythm at first monitoring, and the number of witnessed cardiac arrests significantly increased (p < 0.001). The proportion of TOR cases due to decisions made by a medical director and refusal of CPR by family members also significantly increased, while that due to clear evidence of death decreased (p < 0.001). In conclusion, there was a significant change in the reason for TOR before and after the COVID-19 pandemic in Korea.
Cite this article
Jun Her, Youngsuk Cho, Gyu Chong Cho. Reasons for the termination of resuscitation in out-of-hospital cardiac arrests before and after the COVID-19 pandemic in Korea. Signa Vitae. 2023; 19(3): 137-145. doi: 10.22514/sv.2022.081
1. Introduction
The incidence of out-of-hospital cardiac arrest (OHCA) has been gradually increasing because of the high prevalence of cardiovascular diseases and aging of the population, leading to increased interest in cardiopulmonary resuscitation (CPR) among the public [1]. To improve the survival of OHCA patients, CPR should be performed immediately by any bystander at the scene, and the patient should be transported thereafter to the hospital while receiving prehospital care [2].
Recently, not only basic life support but also advanced life support has been performed at scenes of OHCA; to do this, a multi-tiered ambulance service system, involving the dispatch of two or more ambulances to the scene of cardiac arrest, has been expanded and implemented [3]. In Korea, a two-tiered ambulance service system has been in play since 2016, in which two ambulances are simultaneously dispatched to the emergency scene, including that of OHCAs, to improve the survival rate of cardiac arrest patients. The two-tiered ambulance service system enhances the quality of prehospital patient care by allowing team resuscitation to be performed, with several paramedics arriving at the scene of an OHCA [4]. However, as two ambulances are simultaneously dispatched to the scene of cardiac arrest, the number of ambulance dispatches increases, aggravating the burden of fieldwork for paramedics. Therefore, an efficient dispatch system should be established to minimize unnecessary dispatches to the scene of OHCA [5, 6].
Previous studies on termination of resuscitation (TOR) guidelines for OHCA have actively investigated sorting patients with cardiac arrest who do not have or have little possibility of survival to reduce unnecessary transport of patients to hospitals [7, 8, 9]. It is widely applicable to activities of prehospital patient care worldwide. Notably, the use rate of medical institutions was reduced during the coronavirus disease 2019 (COVID-19) pandemic due to various barriers [10]. However, the number of ambulance dispatches during the COVID-19 pandemic gradually increased [11]. As the number of patients with cardiac arrest in residential areas rose, the number of cases of TOR at the scene of cardiac arrest also gradually increased [12, 13, 14]. It appears that emergency medical service (EMS) is not used efficiently. Therefore, as one of the methods for efficient EMS operation, it is necessary to analyze the size and reason for TOR. However, systematic studies on cases in which paramedics withheld hospital transfers at the scene of an OHCA remain lacking in Korea. Therefore, this study aimed to analyze the reasons for TOR in prehospital cardiac arrest patients and compare them between before and after the COVID-19 pandemic.
2. Participants and methods
2.1 Data collection
This study was conducted using data from prehospital care reports in Seoul for 2 years (01 January 2019–31 December 2020). The data from patients’ prehospital care reports were collected using the “Fire and Emergency Rescue Activity Information Management Reporting System” established at the Seoul Metropolitan Fire and Disaster Headquarters. The following data were collected: demographics and comorbidities, arrest location, the identity of a bystander, cause of cardiac arrest, first monitored electrocardiographic (ECG) rhythm, the reason for TOR, witnessed arrest, and transport to the hospital. OHCA cases with TOR reported to the EMS were included in the study. Patients who experienced cardiac arrest of a non-medical cause and received CPR from EMS paramedics at the scene were excluded from the analysis.
2.2 Control group
In Korea, the incidence of COVID-19 has gradually increased since the first case was confirmed in January 2020. As quarantine measures were gradually strengthened, full-scale social distancing has been implemented since March 2020. In this study, 01 January–31 December 2019, was defined as the pre-COVID-19 period (control group), while 01 January–31 December 2020, was defined as the COVID-19 period (comparative group), and an analysis was conducted to compare data from these periods.
2.3 Statistical analysis
Categorical variables are presented as frequencies and percentages, while continuous variables are presented as medians and interquartile ranges. After the normality test, parametric (independent t-test or chi-square test) or non-parametric (Mann-Whitney U test) methods were used for comparison. All statistical analyses were performed using SPSS Statistics version 18.0 (SPSS Inc., Chicago, IL, USA). p < 0.05 was considered to be statistically significant.
3. Results
3.1 Study participants
During the study period, 22,300 ambulances were dispatched for OHCA in Seoul. Among them, 3801 patients who experienced OHCA due to a non-medical cause and 7627 patients who received CPR from paramedics at the scene were excluded. Overall, only 10,872 cardiac arrest patients whose resuscitation was terminated were included in the analysis (58.8% of 18,499 non-traumatic OHCAs) (Fig. 1).
Fig. 1.Flowsheet of the study. EMS, emergency medical services; OHCA, out-of-hospital cardiac arrest; CPR, cardiopulmonary resuscitation; COVID, Coronavirus disease.
The numbers of non-traumatic OHCA patients in Seoul were 8466 in 2019 and 10,033 in 2020; thus, it is apparent that cases increased significantly during the COVID-19 period. Among them, 4634 (54.7%) patients with TOR were enrolled from the pre-COVID-19 period, and a statistically significant increase to 6238 (62.2%) patients was noted in the COVID-19 period (p < 0.001, Fig. 2).
Fig. 2.Trend of withhold/withdrawal of CPR case. Dark gray bar, withhold/withdrawal of CPR case; light gray bar, CPR performed case. CPR, cardiopulmonary resuscitation; COVID, Coronavirus disease.
3.2 Comparison of characteristics for TOR cases
During the COVID-19 period, the proportion of women decreased (53.1% vs. 37.3%, p < 0.001), but the median age of patients during the COVID-19 period was higher than that of patients during the pre-COVID-19 period (77.0 vs. 75.0, p < 0.001, Table 1).
A total of 6415 (59.0%) patients had comorbidities, and hypertension, diabetes, and cancer were the most common comorbidities in descending order. The numbers of patients with hypertension, diabetes, cancer, and neurovascular diseases were increased significantly in the COVID-19 period (Table 1).
The most frequently observed first monitored ECG rhythm was asystole (9232 cases, 84.9%); the number of patients with asystole significantly increased from 3889 (83.9%) during the pre-COVID-19 period to 5343 (85.7%) during the COVID-19 period (p < 0.001, Table 1).
Most of the cardiac arrests occurred at home (10,160 cases, 93.5%); however, there was no significant difference in cardiac arrest location between before and after the start of the COVID-19 pandemic. A total of 1718 witnessed OHCAs (15.8%) were documented during the study period, with a significant increase from 671 (14.5%) during the pre-COVID-19 period to 1047 (16.8%) during the COVID-19 period (p < 0.001, Table 1). The most common bystanders were family members (7595 cases, 69.6%), whose presence during OHCA significantly increased from 3152 (68.0%) cases during the pre-COVID-19 period to 4443 (71.2%) cases during the COVID-19 period (p = 0.002, Table 1).
| Variables | Total (n = 10,872) | Pre-COVID-19 period (n = 4634) | COVID-19 period (n = 6238) | p(a) | |
| Gender, female(b) | 4604 (43.9) | 2328 (53.1) | 2276 (37.3) | <0.001 | |
| Age, year(b) | 76.0 (60.0–85.0) | 75.0 (60.0–84.0) | 77.0 (62.0–85.0) | <0.001 | |
| Comorbidities(c) | |||||
| Hypertension | 2130 (19.6) | 797 (17.2) | 1333 (21.4) | <0.001 | |
| Diabetes mellitus | 1632 (15.0) | 636 (13.7) | 996 (16.0) | 0.001 | |
| Cancer | 1465 (13.5) | 573 (12.4) | 892 (14.3) | 0.003 | |
| Lung disease | 500 (4.6) | 202 (4.4) | 298 (4.8) | 0.303 | |
| Liver disease | 227 (2.1) | 95 (2.1) | 132 (2.1) | 0.812 | |
| Renal disease | 245 (2.3) | 94 (2.0) | 151 (2.4) | 0.173 | |
| Heart disease | 988 (9.1) | 404 (8.7) | 584 (9.4) | 0.248 | |
| Neurovascular disease | 782 (7.2) | 276 (6.0) | 506 (8.1) | <0.001 | |
| Others | 2265 (20.8) | 926 (20.0) | 1339 (21.5) | 0.060 | |
| Unknown | 3159 (29.1) | 1457 (31.4) | 1702 (27.3) | <0.001 | |
| First monitored ECG rhythm | |||||
| Asystole | 9232 (84.9) | 3889 (83.9) | 5343 (85.7) | <0.001 | |
| PEA/Bradycardia/AED nonshockable | 423 (3.9) | 167 (3.6) | 256 (4.1) | ||
| VF/pVT/AED shockable | 22 (0.2) | 11 (0.2) | 11 (0.2) | ||
| Others, unknown, etc. | 138 (1.3) | 17 (0.4) | 121 (1.9) | ||
| Not recorded | 1057 (9.7) | 550 (11.9) | 507 (8.1) | ||
| Witnessed arrest | |||||
| Not witnessed | 8792 (80.9) | 3781 (81.6) | 5011 (80.3) | <0.001 | |
| Witnessed | 1718 (15.8) | 671 (14.5) | 1047 (16.8) | ||
| Unknown | 362 (3.3) | 182 (3.9) | 180 (2.9) | ||
| Transported to ED | |||||
| Transported | 54 (0.5) | 25 (0.5) | 29 (0.5) | 0.584 | |
| Not transported | 10,818 (99.5) | 4609 (99.5) | 6209 (99.5) | ||
| Arrest location | |||||
| Home/residence | 10,160 (93.5) | 4323 (93.3) | 5837 (93.6) | 0.776 | |
| Medical/assisted living/nursing home | 237 (2.2) | 104 (2.2) | 133 (2.1) | ||
| Sport/recreation event | 244 (2.2) | 105 (2.3) | 139 (2.2) | ||
| Industrial/workplace/public building | 27 (0.2) | 13 (0.3) | 14 (0.2) | ||
| Street/highway | 43 (0.4) | 22 (0.5) | 21 (0.3) | ||
| Others/unknown/not recorded | 130 (1.2) | 57 (1.2) | 73 (1.2) | ||
| In Ambulance | 31 (0.3) | 10 (0.2) | 21 (0.3) | ||
| Bystander | |||||
| Family | 7595 (69.9) | 3152 (68.0) | 4443 (71.2) | 0.002 | |
| Passerby | 313 (2.9) | 137 (3.0) | 176 (2.8) | ||
| Colleague | 415 (3.8) | 192 (4.1) | 223 (3.6) | ||
| Healthcare workers, paramedics | 636 (5.8) | 276 (6.0) | 360 (5.8) | ||
| First responder | 177 (1.6) | 94 (2.0) | 83 (1.3) | ||
| Others | 1736 (16.0) | 783 (16.9) | 953 (15.3) | ||
| COVID, Coronavirus disease; ECG, electrocardiography; PEA, pulseless electrical activity; AED, automated external defibrillator; VF, ventricular fibrillation; pVT, pulseless ventricular tachycardia; ED, emergency department; (a)Comparison between pre-COVID and COVID period; (b)The variables includes the missing value; (c)These variables were counted to duplicate; Categorical variables were expressed by number (%), continuous variables by median (interquartile range). |
3.3 Comparison of the reasons for TOR
The reasons for TOR reported by the paramedics included clear evidence of death, refusal of CPR by family members, decision by the medical director, and the presence of a do-not-resuscitate (DNR) order in advance directives. During the COVID-19 period, the proportion of TOR cases due to decisions by medical directors and refusal of CPR by family members significantly increased, whereas that due to clear evidence of death decreased. Among these patients, only 166 (1.5%) had completed the DNR form in advance directives (Table 2). Clear evidence of death accounted for 2872 cases in 2019, which increased to 3030 cases in 2020; however, the proportion significantly decreased from 62.0% in 2019 to 48.6% in 2020. Refusal of CPR by family members accounted for 30.0% of all reasons for TOR in 2019, and this proportion significantly increased to 36.7% in 2020 during the COVID-19 period. Decisions by medical directors accounted for 6.8% of the reasons for TOR in 2019 but significantly increased to 13.0% in 2020 (Fig. 3).
| Causes | Pre-COVID-19 period (n = 4634) | COVID-19 period (n = 6238) | p |
| Clear evidence of death | 2872 (62.0) | 3030 (48.6) | <0.001 |
| Refusal of family member | 1388 (30.0) | 2289 (36.7) | |
| Decision by medical director | 316 (6.8) | 811 (13.0) | |
| DNR in advance directives | 58 (1.3) | 108 (1.7) | |
| CPR, cardiopulmonary resuscitation; COVID, Coronavirus disease; DNR, do-not resuscitate. |
Fig. 3.Number of withhold/withdrawal of CPR by causes. Starting from the bottom of the bar chart, black bar, clear evidence of death; dark gray bar, refusal of family member; light gray bar, decision by medical director; whitish gray bar, DNR in advance directives. CPR, cardiopulmonary resuscitation; COVID, Coronavirus disease; DNR, do-not resuscitate.
There was no significant difference in the reasons for TOR between before and after the COVID-19 pandemic among patients who did not have comorbidities and were aged <65 years. Patients with comorbidities had increased refusal of CPR by family members in all age groups compared to the pre-COVID-19 period. Among patients without comorbidities, those aged 65–74 years had increased refusal of CPR by family members, but those aged ≥75 years showed no significant difference (48.4% during the pre-COVID-19 period vs. 48.2% during the COVID-19 period; Table 3).
4. Discussion
In this study conducted on patients with OHCA in Seoul, the number of TOR cases confirmed by EMS paramedics increased during the COVID-19 pandemic, and those due to decisions by medical directors and refusal of CPR by family members significantly increased. These results are consistent with those of previous studies reporting a rise in OHCAs occurring at home and an increase in TOR at the scene due to strengthened social distancing and a decrease in patients’ use of medical institutions during the COVID-19 pandemic [15, 16, 17]. In an observational study using an OHCA registry in the United States, Chan et al. [18] found that, in regions with high COVID-19 mortality rates, the number of on-site resuscitation termination cases was more likely to be increased; however, even in areas with relatively low COVID-19 mortality rates, the number of on-site resuscitation termination cases significantly increased.
In our analysis of the reasons for TOR, the number of cases of resuscitation termination due to refusal of CPR by family members was significantly increased during the COVID-19 pandemic. This trend was true across all age groups, particularly among patients with comorbidities. Because of limited access to health care during the COVID-19 pandemic, the proportion of patients with comorbidities who remain at home during cardiac arrest increased, and it is assumed that family members who witnessed the cardiac arrest also refused to be transported to hospitals (Tables 1,2,3).
| Age <65 (n = 1730) | 65≤ Age <74 (n = 1150) | 75≤ Age (n = 4726) | ||||||||
| Pre-COVID-19 period | COVID-19 period | p (a) | Pre-COVID-19 period | COVID-19 period | p (a) | Pre-COVID-19 period | COVID-19 period | p (a) | ||
| No Comorbidities (n = 1270) | ||||||||||
| Clear evidence of death | 164 (85.0%) | 172 (77.1%) | 0.201 | 62 (91.2%) | 42 (71.2%) | 0.009 | 150 (47.2%) | 155 (37.9%) | <0.001 | |
| Refusal of family member | 8 (4.1%) | 14 (6.3%) | 2 (2.9%) | 10 (16.9%) | 154 (48.4%) | 197 (48.2%) | ||||
| Decision by medical director | 21 (10.9%) | 36 (16.1%) | 4 (5.9%) | 7 (11.9%) | 13 (4.1%) | 53 (13.0%) | ||||
| DNR in advance directives | 0 (0.0%) | 1 (0.4%) | 0 (0.0%) | 0 (0.0%) | 1 (0.3%) | 4 (1.0%) | ||||
| Comorbidities (n = 6336) | ||||||||||
| Clear evidence of death | 454 (76.3%) | 462 (64.3%) | <0.001 | 259 (62.4%) | 286 (47.0%) | <0.001 | 592 (39.1%) | 733 (29.5%) | <0.001 | |
| Refusal of family member | 82 (13.8%) | 128 (17.8%) | 116 (28.0%) | 228 (37.5%) | 813 (53.7%) | 1452 (58.4%) | ||||
| Decision by medical director | 52 (8.7%) | 118 (16.4%) | 34 (8.2%) | 75 (12.3%) | 82 (5.4%) | 244 (9.8%) | ||||
| DNR in advance directives | 7 (1.2%) | 11 (1.5%) | 6 (1.4%) | 19 (3.1%) | 26 (1.7%) | 57 (2.3%) | ||||
| CPR, cardiopulmonary resuscitation; COVID-19, Coronavirus disease; DNR, do-not resuscitate. (a) Comparison between pre-COVID and COVID period; Age and comorbidities variables had missing values. Categorical variables were expressed by number (%). |
In Korea, when paramedics terminate cardiac arrest at the scene, they must receive medical supervision from an on-duty EMS medical director [19]. In this study, compared to before the COVID-19 pandemic, decisions made by the medical director increased the rate of TOR, and this result is presumed to have occurred because paramedics declared the termination through medical direction without being sure about the evidence of death (Fig. 3, Table 2). Furthermore, the COVID-19 pandemic itself may have influenced the determination of clear evidence of death. The pandemic situation may have caused a delay in evaluating clear evidence of death until quarantine release, and EMS paramedics could also have been reluctant to evaluate the death. However, further research is needed to verify these findings.
In this study, the number of patients who completed a DNR form in advance directives was small among those who experienced TOR (1.5% of all cases). In Korea, the Act on Decisions on Life-sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life, which allows patients with no possibility of revitalization to not receive life-sustaining treatment by order of themselves or at the consent of their family members, was introduced in 2017. However, official forms are rarely prepared and presented to paramedics at an actual cardiac arrest scene. Considering that the rate of CPR refusal by family members continued to increase in this study, measures for activating DNR in advance directives are necessary for the future (Fig. 3, Table 2).
Hutton et al. [20] confirmed in a study conducted in the United States using the North American Resuscitation Outcomes Consortium Epistry that 1622 out of 27,232 prehospital TOR cases involved a DNR in advance directives and 1018 involved verbal directives given by family. Even after accounting for differences in study participants’ selection, the proportion of verbal directives given by family was lower than that in this study. In contrast, the proportion of DNR orders in advance directives was significantly higher than in this study. This trend is probably due to cultural differences between the East and West regarding the right to self-determination of death.
This study has a strength compared to previous studies because it relied on a large-scale database with a population of about 10 million people. It was conducted among 18,499 non-traumatic OHCA patients in Seoul during a 2-year study period; among them, 58.8% (n = 10,872) of patients experienced TOR. The emergency dispatch protocol in Korea indicates that two ambulances are dispatched promptly when EMS dispatchers recognize a cardiac arrest situation. Determining the need to terminate resuscitation is not implemented during this stage. Therefore, if caregivers or witnesses who call EMS do not proactively express their intention to refuse CPR, paramedics are unaware of this until they arrive at the scene of the cardiac arrest. Consequently, unnecessary ambulance dispatch is likely to occur. As confirmed by the results of this study, more than half of all non-traumatic OHCA patients in Seoul experienced TOR, suggesting the preparation of countermeasures. If a process is added to quickly examine the DNR in advance directives and the intention to refuse CPR at the stage of obtaining EMS calls, the quality of emergency treatment in OHCA situations that require actual resuscitation can be improved by reducing unnecessary ambulance dispatches. This is the clinical implication that our study has. Therefore, further research will be needed for the effective EMS operation of non-traumatic OHCA.
This study had several limitations. First, as a retrospective observational study, it was conducted over a relatively short period of time; our participants are not representative of all OHCA patients in Korea, as this study only targeted those who had experienced TOR among OHCA patients in Seoul. Second, although the COVID-19 period began in January 2020, there could be a gap between the appearance of COVID-19 cases in Seoul and the time of implementing social distancing reinforcement policies. However, the first confirmed case in Korea was diagnosed in January, and the first epidemic was declared in February, so the start of the COVID-19 period in this study differs from the date of the World Health Organization’s pandemic declaration. Third, data quality could be affected herein because only some of the data were collected based on prehospital EMS care reports provided by the Seoul Metropolitan Fire and Disaster Headquarters. Information such as dispatch time, multi-tiered dispatches, and the number of emergency personnel dispatched was omitted, limiting the study results. Fourth, because prehospital care reports are created with the information collected by paramedics in an emergency situation, there may be recall bias among the collected data, which could affect the statistics. Fifth, there were factors that could not be analyzed. Changes in local epidemic peaks and local shelter-in-house policies could have an impact on TOR. Therefore, additional research at the national level should be conducted in the future.
5. Conclusions
In this study conducted on OHCA patients in Seoul, the number of TOR cases confirmed by EMS paramedics increased with the onset of the COVID-19 pandemic. During the COVID-19 pandemic, the rates of decision-making by a medical director and refusal of CPR by family members increased, while the rates of clear evidence of death as a reason for TOR decreased. There was a significant difference in the reasons for TOR before and after the start of the COVID-19 pandemic.
Availability of data and materials
The data that support the findings of this study are available from Seoul Metropolitan Fire and Disaster Headquarters but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available.
Author contributions
The authors confirm contribution to the papers as follows. JH—writing original draft and interpretation of results; YC and GCC—data collection, data analysis, and reviewing.
Ethics approval and consent to participate
This retrospective observational study was conducted using prehospital EMS care reports in Seoul and was approved by the Kangdong Sacred Heart hospital’s institutional review board (No. 2022-10-021). The need for informed consent has been waived owing to its retrospective nature.
Acknowledgment
Not applicable.
Funding
This research received no external funding.
Conflict of interest
The authors declare no conflict of interest.
