1. Termination of Resuscitation (TOR) By Primary Care Paramedics Implementation Trial Research by Ontario’s Base Hospitals in Collaboration with the Sunnybrook Prehospital and Transport Medicine Research Program

2. Purpose of TOR Implementation Trial To demonstrate the feasibility of TOR by PCPs in selected cardiac arrest patients

3. Why should PCPs do TOR? Fewer than 5% of patients survive prehospital cardiac arrest Emergency ambulance transport can be hazardous to motorists, pedestrians, and paramedic A TOR guideline has been developed that is by itself 99.5% accurate in identifying patients who will not survive cardiac arrest Families are comfortable with TOR in the home and support given by paramedics CPR guidelines support the concept of TOR by PCPs

4. Potential Participants in the TOR Implementation Trial Simcoe Cornwall Kitchener-WaterlooYork Muskoka Grey-Bruce-Huron Peel Hamilton Peterborough Timmins Sault Ste Marie

5. TOR Medical Directive TOR medical directive structured similar to other PCP medical directives When you follow and complete the TOR form you will be following the TOR medical directive!

6. Overview of the Paramedic Role in the TOR Implementation Trial Make sure you have the following two documents in front of you : u TOR Paramedic Guide u TOR Paramedic Form The Guide describes how to fill out the Form!Use the Guide whenever you have to fill out the Form.

7. Overview of the Paramedic Role in the TOR Implementation Trial Step 1: Implement the Cardiac arrest protocol and decide whether TOR guideline can be used on your patient Step 2: Answer the TOR Guideline Questions Step 3: Interpret the TOR Guideline Step 4: Patch to the Base Hospital if needed Step 5: Record the Decision of the BHP Step 6: Record the Patient Outcome Step 7: Record Variations from the Protocol Step 8: Record your Comfort Level Step 9: Complete the Call information and submit the form along with your ACR to the Base Hospital in the TOR Implementation Envelope.

8. Step 1 - Implement Cardiac Arrest Protocol On which patients should you consider using the TOR guideline? ALL cardiac arrest patients On which patients should you actually use the TOR guideline? >18 years old No ALS procedures available during the call The cardiac arrest is of presumed cardiac cause. All these must be true to actually use the TOR guideline! If any are not true, do not use the TOR guideline.

9. Step 1 - Implement Cardiac Arrest Protocol On which patients should you complete the Paramedic Form? ALL CARDIAC ARREST CASES!!!! including trauma, DNR, Code 5, drownings etc. For these only the Form needs to be completed only to Step 1.

10. Step 2 – Answer the TOR Guideline Questions Once the Cardiac Arrest Protocols are completed: Answer each question by checking the correct “  ”  Yes OR  Uncertain OR  No Do not make any decision about TOR at this point

11. Step 3 – Interpret the TOR Guideline Check only one of the two choices depending on answers to questions in Step 2 : If you checked “  Yes OR  Uncertain” to any question in Step 2, check the top “  ” in Step 3. Continue Resuscitation and Transport. DO NOT patch to BH. Go to Step 6. If you checked “  No” to ALL questions in Step 2, check the bottom box. Continue Resuscitation. Patch to the BH for consideration of TOR

12. Step 4 – Patch to the BH (if needed) The Patch should occur from the scene but can occur during transport. If unable to establish patch check the “  ” and transport. Present your patch in the exact order outlined in Step 4. Do not deviate from this script. The BHP is filling out a form with same information. Use the exact phrases where possible.

13. Step 5 – Record the decision of the BHP You must always follow the decision of the BHP! If the BHP advised TOR u Check the top “  ” u Counsel caregivers u Arrange disposition of body according to local policy If the BHP advised transport and continued resuscitation u Check the bottom “  ”

14. Step 6 – Record the patient outcome The patient outcome is recorded only when the patient was transported to the ED.

15. Step 7 – Indicate variations from protocol All questions must be answered for every case. Each describes variations from TOR guideline Usually occur in unusual circumstances and does not mean improper care actually occurred Contact the BH if you are unsure of the answers to any of these questions

16. Step 8 – Rate your comfort level Takes into account many aspects of the call Focus on how comfortable you felt using the TOR Guideline

17. Local BH information n TOR Coordinator- Ken Stuebing n Phone - 905-317-5676

18. Step 9 – Complete the Call Information Provide the requested information. Submit the completed Paramedic Form and your yellow copy of the ACR to the BH in the TOR envelope. Complete the information requested on the front of the TOR envelope

19. Questions? n Thanks for your participation!