Knowledge Translation and Implementation

Out-of-Hospital Cardiac Arrest Termination of Resuscitation Rules

Last Full Review: ILCOR 2025
Last Update: 2020

Termination of resuscitation rules following cardiac arrest are used by many emergency medical services (EMS) systems. These rules are intended to differentiate between patients for whom resuscitation can be discontinued and those who might benefit from additional in-hospital treatment. The rules typically include criteria such as, an unwitnessed arrest by EMS or bystanders; no bystander cardiopulmonary resuscitation (CPR); no defibrillation delivered; and no return of spontaneous circulation. Many different rules have been created, but not all have been validated. The ability to discontinue resuscitation has the potential to preserve the dignity of recently deceased, to reduce EMS transport rates and accident risks for EMS professionals, to reduce stress on healthcare resources and to provide a significant savings in healthcare costs. A 2020 International Liaison Committee on Resuscitation (ILCOR) systematic review evaluated the use of termination of resuscitation rules for their ability to reliably predict in-hospital outcomes of death and unfavorable neurologic outcome following out-of-hospital cardiac arrest (Greif et al. 2020, A188). An updated review for 2025 evaluated adult and pediatric out-of-hospital cardiac arrest and the use of termination of resuscitation rules.

 

Evidence Summary

A 2025 ILCOR systematic review and Consensus on Science with Treatment Recommendations (CoSTR) (Lauridsen et al. 2025; Greif et al. 2025, S205) used the adolopment process (Schünemann et al. 2017, 101) with a 2024 systematic review (Smyth et al. 2024, 101) to evaluate studies relevant to termination of resuscitation rules in the prehospital setting. This review included 10 additional observational studies, adding to the 34 studies assessed in a 2020 ILCOR CoSTR (Greif et al. 2020, A188). Evidence from these studies was rated as very low certainty for predicting death and unfavorable neurological outcomes. The performance of various termination of resuscitation rules was summarized with sensitivity and specificity rates for different populations and conditions.

The systematic review by Smyth et al. (Smyth et al. 2024, e2420040) included 43 nonrandomized studies with 29 termination of resuscitation rules, including 15 studies that reported the derivation of 20 termination of resuscitation rules, and 33 studies that reported external data validation of 17 termination of resuscitation rules. This review found that the universal termination of resuscitation rule had the best sensitivity and diagnostic odds ratio, with analysis suggesting the universal termination of resuscitation rule would miss 1.0% of survivors (95% CI, 0.6–1.3%), or one survivor would be missed for every 100 resuscitation attempts (95% CI, 78–167).

In all, three studies assessed termination of resuscitation rules in pediatric populations for the prediction of death. The application of adult termination of resuscitation rules in pediatric cases resulted in missed survivors in one study (Matsui et al. 2023, 109684), while two termination of resuscitation rules derived for pediatric cases (Maryland Institute for Emergency Medical Services Systems [MIEMSS]) score (Harris et al. 2021, 175) and pediatric termination of resuscitation score (Shetty et al. 2024, 110400) have not yet been externally validated.

The ILCOR treatment recommendation (Lauridsen et al. 2025; Greif et al. 2025, S205) for adult out-of-hospital cardiac arrest (OCHA) for 2025 is a conditional recommendation that emergency medical service systems may implement termination of resuscitation rules to assist clinicians in deciding whether to discontinue resuscitation efforts at the scene or to transport to hospital with ongoing CPR. It is suggested that termination of resuscitation rules may only be implemented following local validation of the termination of resuscitation rule with acceptable specificity considering local culture, values and setting.

For pediatric OHCA, because there is insufficient evidence, it is suggested against the use of termination of resuscitation rules to decide whether to terminate resuscitation efforts.

Insights and Implications

The Red Cross guidelines for the use of termination of resuscitation rules have been revised slightly to clarify that the guideline applies to adults with OHCA. The evidence supporting the ILCOR treatment recommendation, while more robust, is in line with the previous recommendation. New for 2025 is inclusion of pediatric cardiac arrest in the evidence evaluation. While work is underway to develop pediatric termination of resuscitation rules, more studies and validation of rules are needed before a guideline can be made. It is important for EMS systems using termination of resuscitation rules to recognize that the evidence concerning the ability of termination of resuscitation rules to discriminate between patients who will die and those who will survive is of very low certainty and that clinical studies are practically nonexistent. Local validation of any termination of resuscitation rule used is essential.

Rapid Response Systems for Adult In-Hospital Patients

Last Full Review: ILCOR 2025

A rapid response team, also known as a medical emergency team, is a group of trained healthcare professionals in hospitals who respond immediately to signs of clinical deterioration of patients with the goal of preventing cardiac arrest, respiratory failure or death. In the United States (U.S.), these teams have become widely adopted and are crucial components of rapid response systems (RRS) by getting the right resources and services to the patients as quickly as possible to prevent adverse outcomes. In a 2015 study (Stolldorf and Jones 2015, 186) of 32 hospitals that completed a survey, all but two had implemented a rapid response team. Similar rates of use were found more recently by Mitchell et al. (Mitchell et al. 2019, e0031). Team structures vary in size, leadership and member expertise. However, it is unclear if rapid response teams or medical emergency teams improve patient outcomes after cardiac arrest. A 2025 International Liaison Committee on Resuscitation (ILCOR) systematic review explored this topic.

 

Evidence Summary

A 2024 ILCOR systematic review and Consensus on Science with Treatment Recommendations (CoSTR) (Allan et al. 2024; Greif et al. 2025,S205) sought to determine if the implementation of a rapid response system, including a Rapid Response Team or Medical Emergency Team for in-hospital adults at risk of cardiac or respiratory arrest, compared to no rapid response system, improves survival outcomes and the in-hospital incidence of cardiac or respiratory arrest. Of the studies that met inclusion criteria for the review, none reported on the outcome of hospital discharge with favorable neurological outcome. Of eight studies reporting on survival to hospital discharge, none demonstrated a statistically significant improvement with a rapid response system (Allan et al. 2024; Greif et al. 2025,S205).

Three randomized controlled trials (RCTs) reported on the effect of rapid response systems on the incidence of in-hospital cardiac arrest (IHCA). The first RCT (Haegdorens et al. 2018, 127) reported cardiac arrest rates of 1.3 versus 1.0 per 1,000 admissions with or without a rapid response system. A second RCT (Jeddian et al. 2016, 212) reported that after implementation of a rapid response system, the proportion of admitted patients who received cardiopulmonary resuscitation (CPR) decreased from 4.86% to 3.61%, but there was no difference between groups after adjustment of the odds ratio. The third study (Piquette et al. 2005, 599) reported a higher cardiac arrest incidence (1.64/1,000) in patients without a rapid response system compared with 1.31/1,000 with a rapid response system (P=0.306; 95% CI, -2.449 to 1.921) (Allan et al. 2024; Greif et al. 2025, S205).

A weak recommendation from ILCOR suggests that hospitals consider the introduction of a rapid response system to reduce the incidence of IHCA (Allan et al. 2024; Greif et al. 2025, S205).

Insights and Implications

In December 2004, the Institute for Healthcare Improvement launched a campaign with the goal of preventing 100,000 unnecessary deaths in United States hospitals over 18 months (Baehrend 2016). One of the six key interventions promoted by the campaign was the deployment of rapid response teams to identify and respond to early signs of patient deterioration. The Joint Commission also recommends early recognition and response systems for patient deterioration. In the U.S., this has led to widespread adoption of rapid response systems. However, it remains unclear what the effect of rapid response systems are on long-term survival with good neurological outcome, and which components (such as clinical observations, lab parameters) in the afferent limb in rapid response systems should be monitored, and at what frequency. Studies are also needed to evaluate the most effective means of escalating assistance, to determine the ideal composition of the response team, and to identify the optimal design of educational programs to improve recognition of patient deterioration.

 

Debriefing of Clinical Resuscitation Performance

Last Full Review: ILCOR 2025
Last Update: 2020

Debriefing is a facilitated discussion conducted after a critical event (such as cardiac arrest resuscitation) that may be structured or unstructured. It is conducted immediately or soon after a resuscitation with the entire team (“hot” debriefing) or hours to days later, often after records review, outcome data and device logs are available (“cold” debriefing). Some healthcare facilities use both forms of debriefing to maximize learning and team development. For resuscitation following cardiac arrest, debriefing may be used to review team performance and communication, decision-making, and patient outcomes, with the goal of learning from the case, improving clinical performance and patient outcomes, identifying system-level issues and, in some cases, to provide emotional support to healthcare professionals. This topic was reviewed by the International Liaison Committee on Resuscitation (ILCOR) in 2020 (Greif et al. 2020, A188) with an updated systematic review in 2025.

 

Evidence Summary

A 2025 ILCOR systematic review and Consensus on Science with Treatment Recommendations (CoSTR) (Nabecker et al. 2024; Greif et al. 2025, S205) focused on the impact of post-event clinical debriefing of healthcare providers performing resuscitation in any clinical setting, compared with no debriefing, on outcomes of resuscitation skills, performance and knowledge, and patient outcomes such as survival and neurological status at discharge. Any kind of debriefing was included following adult, pediatric and neonatal cardiac arrest. Studies using resuscitation quality feedback devices or data recording without in-person reflection or debriefing in educational settings were excluded. Ten nonrandomized studies met inclusion criteria, all with serious risk of bias due to confounding. A wide variety of debriefing strategies were identified, such as audiovisual feedback, oral debriefing, hot and cold debriefings, video-assisted performance-focused debriefings and team debriefings.

For patient-centered outcomes, most studies found no effect on favorable neurological outcome with debriefing, while one study, (Couper et al. 2020, 166) using a Bayesian hierarchical logistic regression model, found a 77% probability that hot debriefings increased the odds of a favorable neurological outcome, while a cold debriefing had a 1% probability of increased odds of favorable neurological outcome (a negative effect). A second study (Wolfe et al. 2014, 1688) reported debriefing was associated with improved favorable neurological outcome (aOR, 2.75; 95% CI, 1.01–7.5; P=0.047). No effect from debriefing was seen on survival to hospital discharge in four studies, while one study (Couper et al. 2020, 166) favored hot debriefings, with a 67% probability of increased odds of survival, but an 11% probability of increased odds of survival with cold debriefings. For the outcome of return of spontaneous circulation (ROSC), four studies showed no effect, one study (Couper et al. 2020, 166) found a 48% probability that hot debriefings increase the odds of ROSC and an 89% probability that cold debriefings increase the odds of ROSC. A second study (Edelson et al. 2008, 1063) reported a ROSC rate of 59% with debriefing and 45% without debriefing (P=0.03), and one study (Heydarzadeh et al. 2020, 60) did not find significant differences between groups for time for a neonate’s color to return to normal; APGAR scores were higher at 1, 5 and 10 minutes in the debriefing group than those reported for other groups (Nabecker et al. 2024; Greif et al. 2025, S205).

For studies of resuscitation skills performance and outcomes of chest compression depth, rate and fraction, evidence was limited and findings mixed, with half showing no effect with debriefing, and half reporting various improvements in compression matrices (Nabecker et al. 2024; Greif et al. 2025, S205).

Adherence to guidelines was reported to be improved with debriefing in 2/2 studies (Skåre et al. 2018, 140; Skåre et al. 2018, 394).

A weak recommendation by ILCOR for 2025 (Nabecker et al. 2024; Greif et al. 2025, S205), based on very low-certainty evidence, suggests performing post-event debriefing after adult, pediatric and neonatal cardiac arrest in all settings.

Insights and Implications

The ILCOR treatment recommendation has changed from 2020. While it still suggests debriefing rescuers after in-hospital or out-of-hospital cardiac arrest, it no longer specifies that the debriefing must be data-driven or focused on performance. In addition, the recommendation now includes neonatal cardiac arrest. The variation in debriefing strategies, outcomes assessed, and populations meant that meta-analysis could not be performed, and ILCOR was unable to determine the most effective type of briefing. No undesirable effects were reported, and the positive effects were viewed as outweighing any possible undesirable effects.