CJEM Articles: Laurie Morrison

Clinical prediction rules are decision-making tools that incorporate three or more variables from the history, physical examination or simple tests. They help clinicians make diagnostic or therapeutic decisions by standardizing the collection and interpretation of clinical data. There is growing interest in the methodological standards for their development and validation. This article describes the methods used to derive the Canadian C-Spine Rule and provides a valuable reference for investigators planning to develop future clinical prediction rules.

Objectives: 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.