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Prehospital vs. emergency department pronouncement of death: a cost analysis

Published online by Cambridge University Press:  21 May 2015

Mathew Cheung ,
Laurie Morrison  and
P. Richard Verbeek
Mathew Cheung
Affiliation:
Department of Emergency Services, Sunnybrook and Women’s College Health Sciences Centre, Toronto, and Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ont
Laurie Morrison*
Affiliation:
Division of Prehospital Care, Department of Emergency Services, Sunnybrook and Women’s College Health Sciences Centre, Toronto, and Division of Emergency Medicine, Department of Medicine, University of Toronto, and Toronto Ambulance Services, Toronto
P. Richard Verbeek
Affiliation:
Division of Prehospital Care, Department of Emergency Services, Sunnybrook and Women’s College Health Sciences Centre, Toronto, and Division of Emergency Medicine, Department of Medicine, University of Toronto, and Toronto Ambulance Services, Toronto
*
Sunnybrook and Women’s College Health Sciences Centre, Rm. BG20, 2075 Bayview Ave., Toronto ON M4N 3M5; 416 480-6056, fax 416 480-6797; phc.research@utoronto.ca

Abstract

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Objective:

National survival rates for out-of-hospital cardiac arrests are less than 5%, and substantial resources are associated with transporting cardiac arrest victims to hospital for emergency department (ED) resuscitation. The low overall survival rate and the identification of predictors of unsuccessful resuscitation have opened debate on the “futility” of transporting such patients to the ED. This study compares the costs of prehospital pronouncement of death to the costs of transporting patients to a hospital ED for physician pronouncement.

Methods:

The study was a retrospective chart review on a matched cohort of out-of-hospital cardiac arrest patients. Patients were included if documentation was adequate and ambulance response time was less than 8 minutes. A cohort of 20 patients pronounced dead in the field were matched to 20 patients pronounced dead in an ED. Cases were matched on 6 evidence-based predictors of unsuccessful resuscitation. Direct medical costs and mean physician and prehospital provider times were compared.

Results:

The total cost of pronouncement of death in the ED was $45.35 higher than the cost of field pronouncement (p < 0.001). Paramedics spent more time delivering care when death was pronounced in the field (83.3 vs. 55.9 min; p < 0.001). Base hospital physicians spent more time when patients were transported to hospital for ED pronouncement (16.3 vs. 4.3 min; p < 0.001). Total provider time for field pronouncement was 15.5 min longer (p = 0.004), but field pronouncement consumed 12.0 min less physician time.

Conclusions:

Paramedic pronouncement of death in the field is less costly than transporting patients to hospital for physician pronouncement. Pronouncement in the field requires more paramedic time but less physician time.

Keywords

emergency medical servicesdeath pronouncementcost identification
Type
Em Advances • Progrès De La MU
Information
Canadian Journal of Emergency Medicine , Volume 3 , Issue 1 , January 2001 , pp. 19 - 25
Copyright
Copyright © Canadian Association of Emergency Physicians 2001

References

1.Cummins, R.Emergency medical services and sudden cardiac arrest: the “chain of survival” concept. Ann Rev Publ Health 1993;14:313–33.CrossRefGoogle ScholarPubMed
2.Eisenberg, MS, Pantridge, JF, Cobb, LA, Geddes, JS.The revolution and evolution of prehospital cardiac care. Arch Intern Med 1996;156:1611–9.Google Scholar
3.Eisenberg, MS, Cummins, RO, Damon, S, Larsen, MP, Hearne, TR.Survival rates from out-of-hospital cardiac arrest: recommendations for uniform definitions and data to report. Ann Emerg Med 1990;19:1249–59.Google Scholar
4.Brison, RJ, Davidson, JR, Dreyer, JF.Cardiac arrest in Ontario: circumstances, community response, role of prehospital defibril-lation and predictors of survival. CMAJ 1992;147:191–9.Google ScholarPubMed
5.Stiell, IG, Wells, GA, Field, BJ.Improved out-of-hospital cardiac arrest survival through the inexpensive optimization of an existing defibrillation program: OPALS study phase II. Ontario Prehospital Advanced Life Support. JAMA 1999;281:1175–81.Google Scholar
6.Bonnin, MJ, Swor, RA.Outcomes in unsuccessful field resuscitation attempts. Ann Emerg Med 1989;18:507–12.CrossRefGoogle ScholarPubMed
7.Bonnin, MJ, Pepe, PE, Kimball, KT, Clark, PS Jr. Distinct criteria for termination of resuscitation in the out-of-hospital setting. JAMA 1993; 270:1457–62.CrossRefGoogle ScholarPubMed
8.Dull, S, Cummins, R, Graves, J, Larson, M.The futility of prehospital resuscitation of “end-of-life” cardiac arrests [abstract]. Ann Emerg Med 1990;19:467.Google Scholar
9.Eisenberg, M, Bergner, L, Hallstrom, A.Paramedic programs and out-of-hospital cardiac arrest: factors associated with successful resuscitation. Am J Public Health 1979;69:30–8.CrossRefGoogle ScholarPubMed
10.Gray, WA, Capone, RJ, Most, AS.Unsuccessful emergency medical resuscitation: Are continued efforts in the emergency department justified? N Engl J Med 1991;325:1393–8.CrossRefGoogle ScholarPubMed
11.Kellermann, AL.Criteria for dead-on-arrivals, prehospital termination of CPR, and do-not-resuscitate orders. Ann Emerg Med 1993;22:47–51.CrossRefGoogle ScholarPubMed
12.Markovchick, V, Cantrill, S, Pons, P.Identification of these non-traumatic cardiac arrest patients for whom ED resuscitive effect are futile. Ann Emerg Med 1990;19:460.Google Scholar
13.Marsden, AK, Ng, GA, Dalziel, K, Cobbe, SM.When is it futile for ambulance personnel to initiate cardiopulmonary resuscitation? BMJ 1995;311:49–51.Google Scholar
14.Pepe, P, Brown, C, Bonnin, M.Prospective validation of criteria for on-scene termination of resuscitation efforts after out-of-hospital cardiac arrest. Ann Emerg Med 1993;22:884–5.Google Scholar
15.Roth, R, Stewart, RD, Rogers, K, Cannon, GM.Out-of-hospital cardiac arrest: factors associated with survival. Ann Emerg Med 1984;13:237–43.CrossRefGoogle ScholarPubMed
16.Kellermann, AL, Hackman, BB.Terminating unsuccessful advanced cardiac life support in the field [editorial]. Am J Emerg Med 1987;5:548–9.CrossRefGoogle ScholarPubMed
17.Frank, M.Should we terminate futile resuscitations in the field? Can we afford not to? [editorial]. Ann Emerg Med 1989;18: 594–6.CrossRefGoogle ScholarPubMed
18.Gray, WA.Prehospital resuscitation. The good, the bad, and the futile [editorial]. JAMA 1993;270:1471–2.CrossRefGoogle ScholarPubMed
19.Jecker, NS, Schneiderman, LJ.An ethical analysis of the use of “futility” in the 1992 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Arch Intern Med 1993;153:2195–8.CrossRefGoogle ScholarPubMed
20.Auerbach, PS, Morris, JA Jr, Phillips, JB, Redlinger, SR, Vaughn, WK.An analysis of ambulance accidents in Tennessee. JAMA 1987;258:1487–90.Google Scholar
21.Hick, JL, Mahoney, BD, Lappe, M.Factors influencing hospital transport of patients in continuing cardiac arrest. Ann Emerg Med 1998;32:19–25.CrossRefGoogle ScholarPubMed
22.Eisenberg, M.Improving out-of-hospital resuscitation. Lancet 1994;344:561–2.CrossRefGoogle ScholarPubMed
23.Jakobsson, J, Nyquist, O, Rehnqvist, N, Norberg, KA.Cost of a saved life following out-of-hospital cardiac arrest resuscitated by specially trained ambulance personnel. Acta Anaesthesiol Scand 1987;31:426–9.CrossRefGoogle ScholarPubMed
24.How to read clinical journals: VII. To understand an economic evaluation (part A). CMAJ 1984;130:1428–34.Google Scholar
25.Council on Health Strategy. Health Manual of Operational Directives and Guidelines. Ontario Ministry of Health, Emergency Health Services; 1997.Google Scholar
26.Stiell, IG, Wells, GA, Spaite, DW, Lyver, MB, Munkley, DP, Field, BJ, et al. The Ontario Prehospital Advanced Life Support (OPALS) Study: rationale and methodology for cardiac arrest patients. Ann Emerg Med 1998;32:180–90.Google Scholar
27.Nichol, G, Laupacis, A, Stiell, IG, O’Rourke, K, Anis, A, Bolley, H, et al. Cost-effectiveness analysis of potential improvements to emergency medical services for victims of out-of-hospital cardiac arrest. Ann Emerg Med 1996;27:711–20.CrossRefGoogle ScholarPubMed
28.Eisenberg, JM.Clinical economics. A guide to the economic analysis of clinical practices. JAMA 1989;262:2879–86.Google Scholar
29.Borenstein, M, Rothstein, H, Cohen, J.Power and Precision. Teaneck (NJ): Biostat; 1997.Google Scholar
30.Delbridge, TR, Fosnocht, DE, Garrison, HG, Auble, TE.Field termination of unsuccessful out-of-hospital cardiac arrest resuscitation: acceptance by family members. Ann Emerg Med 1996; 27:649–54.CrossRefGoogle ScholarPubMed
31.Schmidt, TA, Harrahill, MA.Family response to out-of-hospital death. Acad Emerg Med 1995;2:513–8.CrossRefGoogle ScholarPubMed
32.Redelmeier, DA, Morrison, LJ.Record keeping and compassionate care [letter]. Lancet 1998;352:2025.CrossRefGoogle ScholarPubMed