Original Contribution Applicability of the prehospital termination of resuscitation rule in an area dense with hospitals in Tokyo: a single-center, retrospective, observational study ☆ , ☆☆ , ★ , ★★ Is the pre hospital TOR rule applicable in Tokyo? Tatsuma Fukuda, MD ⁎, Naoko Ohashi,MD, Takehiro Matsubara, MD, PhD, Kent Doi,MD, PhD, Masataka Gunshin, MD, Takeshi Ishii,MD, Yoichi Kitsuta,MD, PhD,Susumu Nakajima, MD, PhD, Naoki Yahagi,MD, PhD Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo,113-8655, Japan a b s t r a c t a r t i c l e i n f o Article history: Received 8 September 2013 Received in revised form 1 October 2013 Accepted 18 October 2013 Background: It is unclear whether the prehospital termination of resuscitation (TOR) rule is applicable in specific situations such as in areas extremely dense with hospitals. Objectives: The objective ofthe study is to assess whether the prehospital TOR rule is applicable in the emergency medical services system in Japan, specifically, in an area dense with hospitals in Tokyo. Methods: This study was a retrospective,observationalanalysis of a cohort of adult out-of-hospital cardiopulmonary arrest (OHCA) patients who were transported to the University of Tokyo Hospital from April 1,2009,to March 31,2011. Results: During the study period, 189 adult OHCA patients were enrolled. Of the 189 patients, 108 patients me the prehospital TOR rule. The outcomes were significantly worse in the prehospital TOR rule–positive group than in the prehospitalTOR–negative group, with 0.9% vs 11.1% of patients,respectively,surviving until discharge (relative risk [RR], 1.11; 95% confidence interval [CI], 1.03-1.21; P = .0020) and 0.0% vs 7.4% of patients,respectively,discharged with a favorable neurologic outcome (RR, 1.08; 95% CI,1.02-1.15; P = .0040).The prehospitalTOR rule had a positive predictive value (PPV) of 99.1% (95% CI, 96.3-99.8) and a specificity of 90.0% (95% CI, 60.5-98.2) for death and a PPV of 100.0% (95% CI, 97.9-100.0) and a speci ficity o 100.0% (95% CI, 61.7-100.0) for an unfavorable neurologic outcome. Conclusions: This study suggested that the prehospital TOR rule predicted unfavorable outcomes even in an area dense with hospitals in Tokyo and mightbe helpful for identifying the OHCA patients for whom resuscitation efforts would be fruitless. © 2013 Elsevier Inc. All rights reserved. 1. Introduction Out-of-hospitalcardiopulmonary arrest (OHCA) has one ofthe worst prognoses,and approximately 120 000, 280 000,and 380000 people per year develop OHCA in Japan, Europe, and the United States, respectively [1-3]. Of these patients, approximately 60% in Europe and 55% in the United States are transferred to hospitals, whereas almost all OHCA patients (96%) in Asia are transferred to hospitals [4-8]. In Japan,a nonphysician is legally unable to make the decision to terminate resuscitation [4,9-11]. In an ambulance, in which there is usually no physician, resuscitation efforts are conducted on almost all OHCA patients regardless of whether they have an advance directive, living will, and/or do-not-attempt-resuscitation order [4,9-11]. In our previous study, which was conducted using the nationwide administrative database in Japan, we found the following outcomes of the OHCA patients transferred to emergency hospitals: approximately 75% died within 24 hours after arrival at the hospital, approximately 17% survived more than 24 hours but died during hospitalization, and approximately 8% survived to discharge. The medical costs of hospitalization per OHCA patient who died within 24 hours amounted to approximately $1500, the exchange rate assumed to be 80 Japanese yen per US $1 [4]. American Journal of Emergency Medicine 32 (2014) 144–149 ☆ This manuscript has not been published or presented elsewhere in part or in entirely and is not under consideration by another journal. ☆☆ Contributors: T Fukuda, as principal investigator, participated in idea formation, study design, and completion, data collection, data management,data analysis, interpretation of results, and revision of the report and contributed to the final report. N Ohashi,T Matsubara,K Doi,M Gunshin,T Ishii,Y Kitsuta,S,Nakajima,and N Yahagi participated in idea formation, data collection, data management, and interpretation of results.T Fukuda did the statistical analysis. All authors approved the final version. ★ Funding sources: We did not receive any financial support for this study. ★★ Conflict of interest statement: We declare that we have no conflicts of interest. ⁎ Corresponding author. Tel.: +81 3 3815 5411; fax: +81 3 3814 6446. E-mail address: tatsumafukuda-jpn@umin.ac.jp (T. Fukuda). 0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajem.2013.10.032 Contents lists available at ScienceDirect American Journal of Emergency Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / a j e m