Inter-Rater Reliability and Acceptability of a Clinical Prediction Rule for Opioid-Associated Out-of-Hospital Cardiac Arrest

One-in-six cases of atraumatic out-of-hospital cardiac arrest (OHCA) in North America are thought to be precipitated by opioid overdose, but many of these cases are not obvious and there is no gold standard used by emergency medical service (EMS) personnel to identify opioid-associated (OA)-OHCA. The NAloxone Cardiac ARrest Decision Instrument (NACARDI) was developed and validated to identify potential OA-OHCA, however it has not yet been used in the field. We sought to prospectively assess the inter-rater reliability and acceptability of NACARDI in real-world OHCA. Emergency medical service clinicians evaluated the NACARDI criteria during acute resuscitations of patients with OHCA in San Francisco between September 2022–February 2024. The NACARDI rule utilized in this study consisted of two criteria: patient age <60 years and unwitnessed cardiac arrest. Clinicians completed a short survey that included free-text questions, multiple choice question, and Likert-type scales rating NACARDI’s ease of use, describing when during the resuscitation they were able to assess NACARDI, and identifying potential barriers. In cases where two clinicians completed NARCADI assessments for a single OHCA case, we calculated a kappa coefficient of agreement. Emergency medical service clinicians evaluated 149 cases of OHCA and completed 198 surveys − 100 (67.1%) cases had one survey response and 49 (32.9%) had survey responses from two EMS personnel. Clinicians were able to ascertain NACARDI criteria “prior to or during the first cardiac rhythm check” in 80.3% of cases. NACARDI was reported as “easy to use” by 83.3% of respondents. The overall Kappa coefficient for NACARDI was 0.73 (95%CI 0.51–0.95). The three most common reasons why NACARDI criteria were deemed difficult to ascertain were chaotic scene, language barrier, and unreliable bystander accounts. There was reasonable agreement in how NACARDI was interpreted for OHCA cases and the majority of surveyed EMS clinicians found NACARDI easy to use. These findings suggest that NACARDI can be reliably and easily used by EMS clinicians during acute OHCA resuscitations to identify OA-OHCA patients, potentially informing inclusion criteria for future research studies and guiding targeted interventions for this patient population.