The reluctance of house staff to perform mouth-to-mouth resuscitation in the inpatient setting: what are the considerations?

Community life support training: does it attract the right people?

Members of the public recruited by means of a local newspaper campaign for basic life support instruction by mass training sessions. Six hundred and seventy-two were trained and a random sample of 241 completed a questionnaire on their attitudes and willingness to attempt cardiopulmonary resuscitation in an emergency. At the end of the course almost all (99%) approved the concept of community training and 198 (82%) believed themselves capable of saving a life using the techniques they had been taught. Sixty-seven percent of respondents were related to someone with a heart problem and more than 97% expressed willingness to resuscitate a relative. Half would be willing to attempt resuscitation in unpleasant circumstances, but only a quarter thought that they might do so if the casualty had vomited. The campaign was successful in recruiting members of the public related to those with a higher risk of cardiac arrest and producing life supporters who intended to use their skills, should they be required.

Reluctance of paramedics and emergency medical technicians to perform mouth-to-mouth resuscitation

Recently, a reluctance of lay and medical personnel to perform mouth-to-mouth resuscitation (MMR) in hospital and community settings has been documented, with 45% of respondents declining to perform MMR on a stranger. In the present study, we examined whether the perceived risk and fear of contracting infectious diseases diminishes the willingness of paramedics and emergency medical technicians (EMTs) to perform MMR. Seventy-seven EMTs and 27 paramedics responded to a questionnaire, administered by one of two physicians, containing mock cardiac arrest scenarios that were designed to assess willingness to perform MMR as a citizen responder. Faced with a situation in which an adult stranger required MMR, 57% of the participating EMTs and all of the paramedics stated that they would refuse to perform MMR. None of the paramedics and only 32.5% of the EMTs stated that they would perform MMR on a man in a gay neighborhood. In addition, 23% of the EMTs and 37% of the paramedics indicated that they would refuse to perform MMR on a child. White respondents were more willing than nonwhite respondents to perform MMR. Twenty-nine percent of the prehospital-care providers had been in situations requiring MMR in the community, and 40% either had walked away or did only external compression. Of those participating paramedics and EMTs who had performed MMR in emergency situations, only 45% indicated that they would do so again. The respondents indicated that they would not be willing to administer MMR because of the fear of contracting infectious agents, especially the human immunodeficiency virus. Despite the proven effectiveness of MMR in saving lives, paramedics and EMTs are highly reluctant to perform MMR as citizen responders. Their perceived risks of contracting infectious agents during MMR are high, despite the low actual risks. We recommend that instruction in cardiopulmonary resuscitation for providers of pre-hospital care, the medical community, and the general public should emphasize the benefits of providing MMR, the actual low risks of contracting infectious diseases during administration of MMR, and the use of widely available and effective barrier masks to minimize any risks due to administration of MMR.

Comparison of the reluctance of house staff of metropolitan and suburban hospitals to perform mouth-to-mouth resuscitation

BACKGROUND

Although performing mouth-to-mouth resuscitation (MMR) during cardiopulmonary resuscitation (CPR) is an effective lifesaving procedure, both the general public and physicians are often unwilling to perform CPR. Fear of contracting infectious diseases, especially AIDS, is often stated as the reason for this reluctance. However, the likelihood of saving a life usually outweighs the chance of contracting an infectious disease, especially when victims are considered to be at low risk for being HIV+ and are in communities with low incidences of HIV antibodies.

METHODS

The entire housestaff (58 residents) in the Department of Internal Medicine of a suburban hospital responded to a questionnaire of hypothetical cardiac arrest scenarios in both inpatient and outpatient settings. Their responses were compared to those previously obtained from the housestaff (82 residents) of a hospital in a large metropolitan area with a high incidence of HIV positive patients.

RESULTS

The willingness of the suburban housestaff (residents) to perform MMR in the inpatient scenario of a patient with an unknown risk for communicable infections was 43%, with trauma was 12%, with a perceived high risk for being HIV+ was 14%, and in the elderly was 29%, compared to 45, 16, 7 and 39%, respectively of the house staff of the metropolitan hospital. In outpatient scenarios, the willingness of the suburban housestaff to perform MMR on a victim with an unknown risk for communicable infections was 50%, with trauma was 33%, with a perceived high risk for being HIV+ was 34%, in the elderly was 26%, and in a child was 86%, compared to 54, 36, 21, 65, and 99%, respectively, of the metropolitan residents. Overall, the suburban male residents were more likely to be willing to perform MMR than the female ones, as were residents actively practising a religion or having graduated from medical schools in the United States. Suburban residents under 30 years of age seemed more willing to perform MMR in the majority of the scenarios than those over 30 years of age. Of the 31 suburban residents that stated they would be unwilling to perform MMR in at least one of the given scenarios, all stated that their unwillingness was due to fear of becoming infected with HIV or other infectious agents. In 1994, the percentage of known HIV positive individuals admitted to the suburban hospital was approximately five times less than that of the metropolitan hospital whose house staff was interviewed (P < 0.001).

CONCLUSIONS

Patients perceived to be at high risk for HIV were less likely to receive MMR than those at low risk. The reluctance of house staff to perform MMR in a suburban community hospital with a low incidence of HIV+ patients is similar to that of house staff in a large metropolitan community with a much higher incidence of infected patients. This reluctance, which was largely due to fear of contracting HIV infections, is not influenced by frequent contact with patients infected with HIV but is based on perceived rather than actual risks of contracting HIV. To increase the willingness of physicians, other medical personnel, and the lay public to perform MMR on victims of cardiac and respiratory arrests, the negligible risk of contracting infectious diseases while performing MMR should be emphasized. Use of portable barrier masks while performing MMR and an increase in their availability would decrease the minimal risks even further, and is recommended by the authors.

Response to cardiac arrests in a hospital setting: delays in ventilation

The outcome following a cardiac arrest is affected by the length of time that elapses before cardiopulmonary resuscitation is initiated. Only 10-15% of patients experiencing cardiac arrest in hospital settings survive to discharge. Therefore, the time between cardiac arrest and administration of cardiopulmonary resuscitation in a metropolitan hospital was examined. All cardiac and respiratory arrests that occurred in the adult non-intensive care areas of a medical center over a period of 16 months were evaluated within 12 h to determine how much time had elapsed before resuscitation was initiated, the devices utilized for initial airway management, and the outcome. To initiate ventilation, bag-valve-masks (BVMs) were used in the majority (76%) of the efforts to resuscitate while mouth-to-mask resuscitation was performed in another 18%; however, in only 37% of the codes was ventilation initiated within 1 min and in 18% ventilation was started after 3 min. Mouth-to-mask resuscitation resulted in more rapid time to onset of ventilation than BVM. In only 18% of the arrests studied was a 'lay-on' mask available in the room and utilized. In 11%, a bag-valve-mask was at the patient's bedside, and in 53% a BVM was taken from the crash cart outside the room. In 63% of the cases where using a lay-on mask was appropriate, it was either not looked for or not present in the patient's room. Also in 37% of the cases where a BVM was needed, one was not readily present because of difficulty in locating the crash cart immediately. Although initiation of cardiopulmonary resuscitation within a minute of a cardiac or respiratory arrest is the standard of care, in the non-intensive care in-patient cases surveyed, typically more than a minute elapsed, and frequently 3 or more minutes, before resuscitation was started. If the time elapsing before an arresting in-patient is ventilated can be shortened, which is easily and effectively achieved by mouth-to-mouth or mouth-to-mask resuscitation, an increase in both the survival rate and the number of good neurological outcomes should be expected.

Teaching schoolchildren cardiopulmonary resuscitation

Forty-one children aged 11-12 years received tuition in cardiopulmonary resuscitation (CPR) and subsequently completed questionnaires to assess their theoretical knowledge and attitudes their likelihood of performing CPR. Although most children scored well on theoretical knowledge, this did not correlate with an assessment of practical ability using training manikins. In particular only one child correctly called for help after the casualty was found to be unresponsive, and none telephoned for an ambulance before starting resuscitation. These omissions have important implications for the teaching of CPR and the resulting effectiveness of community CPR programmes.