Out-of-hospital personnel must make critical decisions on a daily basis, including assessments of whether a patient is definitively dead and, consequently, if resuscitation is required. Several evidence-based guidelines exist to direct these decisions; however, few data discuss the characteristics of these events or the degree of compliance with such protocols. We sought to determine the characteristics and evaluate protocol compliance for prehospital death determination (PHDD) events.
Methods From June to December 2004, all PHDD events were systematically reviewed. Patients met inclusion criteria if paramedics evaluated them and invoked the PHDD protocol. A detailed, data collection form and predetermined data dictionary were utilized for chart abstraction. EMS agencies and personnel were blinded to the study details and purpose. Charts were abstracted by two trained abstractors, and additional accuracy was confirmed by systematic monitoring by the principal investigator. Descriptive statistics were performed using MS Excel.
Results During the study period, there were 674 PHDD events. The average scene time was 22.7 (± SEM 1.02) minutes (range = 1-280 minutes). Victims were most likely to be found in a private residence (522, 77.4%), a nursing home (35, 5.2%), or a hotel/casino (32, 4.7%). Bystander CPR was performed in 81 (12%) cases, and a bystander AED was applied in 8 (1.2%) cases. 255 (37.8%) were female and the mean (± SEM) age was 59.7 (± 0.8) years (range = 7 mo -98 yrs). The majority of cases involved medical causes (n = 500, 74.2%).
Protocol Compliance PHDD criteria (all four presumptive signs of death and at least one conclusive sign of death) were satisfied in 473 (70.2%) cases. Almost 30% of cases represented protocol violations, and of these, 169 (84%) were deemed appropriate by the physician reviewers, and 16 (8%) had clear indications to initiate resuscitation.
Limitations This study is limited by its retrospective nature and its restriction to a single EMS system.
Conclusion PHDD events occur primarily in males, private residences, and as the result of medical issues. In our EMS system, an opportunity remains to improve these assessments. Our findings may have important educational and performance implications for similar EMS systems.
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