Part 8: Education, implementation, and teams

Effectiveness of dispatcher instructions-dependent or independent bystander cardiopulmonary resuscitation on neurological survival among patients with out-of-hospital cardiac arrest

BACKGROUND

We evaluated the association between survival and bystandercardiopulmonary resuscitation (CPR) with or without dispatcher instructions (DI) considering the time from emergency call receipt by the dispatch center to emergency medical services (EMS) personnel's contact with the patient (i.e. time to EMS arrival).

METHODS

This prospective study conducted in Osaka City, Japan, from 2009 to 2015 included patients with medical cause-related out-of-hospital cardiac arrest who were ≥18 years old. The primary outcome was one-month favorable neurological survival. Using multiple logistic regression models, the adjusted odds ratios (AOR) of independent and DI-dependent CPR for the primary outcome were compared with no CPR. Adjustments were made for patients' age, sex, activities of daily living before the cardiac arrest, year of cardiac arrest, location, presence or absence of witnesses, etiology of cardiac arrest, and the time from EMS contact with the patient to patient's arrival at the hospital. The effective estimated "time to EMS arrival" was also calculated.

RESULTS

For analyses 10,925 individuals were eligible. Independent CPR had a significantly higher one-month favorable neurological survival than no CPR whereas there was no significant difference between DI-dependent CPR and no CPR (AOR, 1.90 [1.47-2.46] and 1.16 [0.91-1.47], respectively). The estimated "time to EMS arrival" for a one-month favorable neurological survival after independent CPR was ≤13min.

CONCLUSIONS

Bystander CPR that did not need DI was associated with significantly higher one-month favorable neurological survival than no CPR, with an effective estimated "time to EMS arrival" of ≤13min.

Basic life support training using shared mental models improves team performance of first responders on normal wards: A randomised controlled simulation trial

INTRODUCTION

Survival of in-hospital cardiac arrest (IHCA) depends on fast and effective action of the first responding team. Not only technical skills, but professional teamwork is required. Observational studies and theoretical models suggest that shared mental models of members improve teamwork. This study investigated if a training on shared mental models, improves team performance in simulated in-hospital cardiac arrest.

METHODS

On the background of an introduction of mandatory Basic Life Support (BLS) training for clinical staff a randomized controlled trial was performed to compare two training methods. Staff from clinical departments was randomised to receive either a conventional instructor led training (control group) or an interventional training (intervention group). The interventional training was based on self-directed learning of the group in order to develop shared mental models. Primary outcome were mean scores of the team assessment scale (TAS) and the hands-off time. Secondary outcome were mean scores for quality of BLS.

RESULTS

Performance of 75 teams of the interventional and 66 of the control group was analysed. The hands-off time was significantly lower in the interventional group (5.42% vs. 8.85%, p = 0.029). Scores of the TAS and the overall BLS score were high and not significantly different between the groups. Hands-off time correlated significantly negative with all TAS items.

CONCLUSION

BLS training for clinical staff which creates shared mental models reduces hands-off time in a simulated cardiac arrest scenario. Training methods establishing shared mental models of team members can be considered for effective team trainings without adding additional training time.

Feasibility and preliminary validity evidence for remote video-based assessment of clinicians in a global health setting

BACKGROUND

Serious childhood illnesses (SCI), defined as severe pneumonia, severe dehydration, sepsis, and severe malaria, remain major contributors to amenable child mortality worldwide. Inadequate recognition and treatment of SCI are factors that impact child mortality in Botswana. Skills assessments of providers caring for SCI have not been validated in low and middle-income countries.

OBJECTIVE

To establish preliminary inter-rater reliability, validity evidence, and feasibility for an assessment of providers who care for SCI using simulated patients and remote video capture in community clinic settings in Botswana.

METHODS

This was a pilot study. Four scenarios were developed via a modified Delphi technique and implemented at primary care clinics in Kweneng, Botswana. Sessions were video captured and independently reviewed. Response process and internal structure analysis utilized intra-class correlation (ICC) and Fleiss' Kappa. A structured log was utilized for feasibility of remote video capture.

RESULTS

Eleven subjects participated. Scenarios of Lower Airway Obstruction (ICC = 0.925, 95%CI 0.695-0.998) and Hypovolemic Shock from Severe Dehydration (ICC = 0.892, 95%CI 0.596-0.997) produced excellent ICC among raters while Lower Respiratory Tract Infection (LRTI, ICC = 0, 95%CI -0.034-0.97) and LRTI + Distributive Shock from Sepsis (0.365, 95%CI -0.025-0.967) were poor. Oxygen therapy (0.707), arranging transport (0.706), and fluid administration (0.701) demonstrated substantial task reliability.

CONCLUSIONS

Initial development of an assessment tool demonstrates many, but not all, criteria for validity evidence. Some scenarios and tasks demonstrate excellent reliability among raters, but others may be limited by manikin design and study implementation. Remote simulation assessment of some skills by clinic-based providers in global health settings is reliable and feasible.

Effectiveness of web-based education in addition to basic life support learning activities: A cluster randomised controlled trial

BACKGROUND

Effective education in basic life support (BLS) may improve the early initiation of high-quality cardiopulmonary resuscitation and automated external defibrillation (CPR-AED).

AIM

To compare the learning outcome in terms of practical skills and knowledge of BLS after participating in learning activities related to BLS, with and without web-based education in cardiovascular diseases (CVD).

METHODS

Laymen (n = 2,623) were cluster randomised to either BLS education or to web-based education in CVD before BLS training. The participants were assessed by a questionnaire for theoretical knowledge and then by a simulated scenario for practical skills. The total score for practical skills in BLS six months after training was the primary outcome. The total score for practical skills directly after training, separate variables and self-assessed knowledge, confidence and willingness, directly and six months after training, were the secondary outcomes.

RESULTS

BLS with web-based education was more effective than BLS without web-based education and obtained a statistically significant higher total score for practical skills at six months (mean 58.8, SD 5.0 vs mean 58.0, SD 5.0; p = 0.03) and directly after training (mean 59.6, SD 4.8 vs mean 58.7, SD 4.9; p = 0.004).

CONCLUSION

A web-based education in CVD in addition to BLS training enhanced the learning outcome with a statistically significant higher total score for performed practical skills in BLS as compared to BLS training alone. However, in terms of the outcomes, the differences were minor, and the clinical relevance of our findings has a limited practical impact.

ABCDE approach to victims by lifeguards: How do they manage a critical patient? A cross sectional simulation study

Introduction

Decision-making in emergencies is a multifactorial process based on the rescuer, patient, setting and resources. The eye-tracking system is a proven method for assessing decision-making processes that have been used in different fields of science. Our aim was to evaluate the lifeguards’ capacity to perform the ABCDE (Airway-Breathing-Circulation-Disability-Exposure) approach when facing a simulated critically ill-drowned victim.

Methods

A cross-sectional simulation study was designed to assess the skills and sequence of the ABCDE approach by 20 professional lifeguards. They had to assess a victim and act according to his/her clinical status by following the ABCDE primary assessment approach. The two kinds of variables were recorder: those related to the quality of each step of the ABCDE approach and the visual behaviour using a portable eye-movement system. The eye-tracking system was the Mobile Eye system (Bedford, USA).

Results

None of the study participants were able to complete correctly the ABCDE approach. Lifeguards spent more time in the Circulation step: Airway (15.5±11.1 s), Breathing (25.1±21.1 s), Circulation (44.6±29.5 s), Disability (38.5±0.7 s). Participants spent more time in viewpoints considered as important (65.5±17.4 s) compared with secondary ones (34.6±17.4 s, p = 0.008). This was also represented in the percentage of visual fixations (fixations in important viewpoints: 63.36±15.06; fixation in secondary viewpoints: 36.64±15.06; p = 0.008).

Conclusion

Professional lifeguards failed to fully perform the ABCDE sequence. Evaluation by experts with the help of eye-tracking technology detected the lifeguards’ limitations in the assessment and treatment of an eventual critically ill victim. Such deficits should be considered in the design and implementation of lifeguards’ training programmes.

Associations between cardiopulmonary resuscitation (CPR) knowledge, self-efficacy, training history and willingness to perform CPR and CPR psychomotor skills: A systematic review

AIM

To determine whether training history (including number of times and duration since last training), knowledge, self-efficacy or willingness are associated with cardiopulmonary resuscitation (CPR) psychomotor skills.

METHODS

Eight databases were systematically searched from January 2005 to February 2018 for articles that involved adult layperson participants and explored an association between training history, knowledge, self-efficacy or willingness and CPR psychomotor skills or survival outcomes after real CPR attempts.

RESULTS

Thirty-four articles with a total of 35,421 participants were included. CPR training was found to improve psychomotor skills, compared to no training, and any previous training was associated with better skills, compared to no previous training, however only the use of a popular song promoted meaningful retention of a specifically targeted skill, compared to standard training methods. Skills deteriorated within 3 months, then plateaued from 3 to 6 months. Self-efficacy was weakly associated with skill level, however knowledge was not associated with skill level. No studies assessed the association between willingness and psychomotor skills.

CONCLUSION

All laypeople should attend an instructor-led CPR training session with real-time or delayed feedback to improve CPR skills. Training sessions should utilise combinations of validated skill-specific training strategies, preferably including popular songs and feedback to help ensure skills retention. Refresher training, which focusses on skills and self-confidence rather than knowledge, should be undertaken every 3-6 months, although this timeframe needs further validation. All future studies assessing CPR psychomotor skills should adhere to a standardised reporting outcome list (proposed in this paper) to ensure consistency and comparability of results.

Self-learning training versus instructor-led training for basic life support: A cluster randomised trial

AIM

To compare the effectiveness of two basic life support (BLS) training interventions.

METHODS

This experimental trial enrolled 1301 lay people in BLS training. The participants were cluster randomised to either self-learning training or to traditional instructor-led training. Both groups used the Mini-Anne Kit (Laerdal Medical, Stavanger, Norway) and standardised film instructions. After training, the participants practical skills were measured on a Resusci Anne manikin and an AED trainer with the PC SkillReporting system (Laerdal Medical, Stavanger, Norway). The primary outcome was the total score from the modified Cardiff Test of basic life support with automated external defibrillation (19-70 points), six months after training. The secondary outcomes were total score directly after training and quality of individual variables, self-assessed knowledge, confidence and willingness to act, directly and six months after training.

RESULTS

For primary outcome six months after training there was no statistically significant difference (p = 0.44) between the total score for the self-learning group (n = 670; median 59, IQR 55-62) compared with the instructor-led group (n = 561; median 59, IQR 55-63). The instructor-led training resulted in a statistically significant higher total score (median 61 versus 59, p < 0.0001), self-assessed knowledge and willingness to act, directly after training (secondary outcomes) compared with the self-learning training.

CONCLUSIONS

There was no statistically significant difference in practical skills or willingness to act when comparing self-learning training with instructor-led training six months after training in BLS. However, directly after the intervention, practical skills were better when the training was led by an instructor.

Does care at a cardiac arrest centre improve outcome after out-of-hospital cardiac arrest? - A systematic review

AIM

To perform a systematic review to answer 'In adults with attempted resuscitation after non-traumatic cardiac arrest does care at a specialised cardiac arrest centre (CAC) compared to care in a healthcare facility not designated as a specialised cardiac arrest centre improve patient outcomes?'

METHODS

The PRISMA guidelines were followed. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 1st August 2018. Randomised controlled trials (RCTs) and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using ROBINS-I tool and GRADEpro respectively. Primary outcomes were survival to 30 days with favourable neurological outcomes and survival to hospital discharge with favourable neurological outcomes. Secondary outcomes were survival to 30 days, survival to hospital discharge and return of spontaneous circulation (ROSC) post-hospital arrival for patients with ongoing resuscitation. This systematic review was registered in PROSPERO (CRD 42018093369) RESULTS: We included data from 17 observational studies on out-of-hospital cardiac arrest (OHCA) patients in meta-analyses. Overall, the certainty of evidence was very low. Pooling data from only adjusted analyses, care at CAC was not associated with increased likelihood of survival to 30 days with favourable neurological outcome (OR 2.92, 95% CI 0.68-12.48) and survival to 30 days (OR 2.14, 95% CI 0.73-6.29) compared to care at other hospitals. Whereas patients cared for at CACs had improved survival to hospital discharge with favourable neurological outcomes (OR 2.22, 95% CI 1.74-2.84) and survival to hospital discharge (OR 1.85, 95% CI 1.46-2.34).

CONCLUSIONS

Very low certainty of evidence suggests that post-cardiac arrest care at CACs is associated with improved outcomes at hospital discharge. There remains a need for high quality data to fully elucidate the impact of CACs.

Assessment of cardiopulmonary resuscitation knowledge and skills among healthcare providers at an urban tertiary referral hospital in Tanzania

Background

Early and effective CPR increases both survival rate and post-arrest quality of life. In limited resource countries like Tanzania, there is scarce data describing the basic knowledge of CPR among Healthcare providers (HCP). This study aimed to determine the current level of knowledge on, and ability to perform, CPR among HCP at Muhimbili National Hospital (MNH).

Methods

This was a descriptive cross sectional study of a random sample of 350 HCP from all cadres and departments at MNH from October 2015 to March 2016. Each participant completed a with 25 question multiple choice and fill-in-the-blank CPR test and a practical test using a CPR manikin where the participant was videotaped for 1–2 min. Two expert observers independently viewed the videos and rated participant performance on a structured data form. The primary outcome of interest was staff member overall performance on the written and practical CPR testing.

Results

We enrolled 350 HCPs from all 12 MNH clinical departments. The median participant age was 35 (IQR 29–43) years, 225 (64%) were female and 138 (39%) had clinical experience of less than 5 years. Only 57 (16%) and 88 (25%) scored above 50% in written and practical tests, respectively according to local minimum passing test score and 13(4%) and 30 (9%) scored above 75% in written and practical tests, respectively according to international minimum passing test score on CPR. The 233(67%) HCP who reported prior experience performing CPR on an adult patient scored higher on testing than those without; 40% (IQR 28–54) versus 26% (IQR 16–42) respectively, but both groups had median scores <50%.

Conclusion

The level of CPR knowledge and skills displayed by all cadres and in all departments was poor despite the fact that most providers reported having performed CPR in the past. Since MNH is a tertiary referral hospital, it may reflect the performance of resuscitation status of other local health centers in Tanzania and other low-income countries to employ a formal system of training every HCP in CPR. Staff should be certified and assessed regularly to ensure retention of resuscitation knowledge and skills.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3725-2) contains supplementary material, which is available to authorized users.

A Smartphone Application to Reduce the Time to Automated External Defibrillator Delivery After a Witnessed Out-of-Hospital Cardiac Arrest: A Randomized Simulation-Based Study

INTRODUCTION

We developed a new smartphone application to deliver an automated external defibrillator (AED) to out-of-hospital cardiac arrest scene. The aim of this study was to evaluate whether an AED could be delivered earlier with or without an application in a simulated randomized controlled trial.

METHODS

Participants, who were asked to work as bystanders, were randomly assigned to either an application group or control group and were asked to bring an AED in both groups. The bystanders in the application group sent a signal notification using the application to two responders, who were stationed within 200 meters of the arrest scene, to carry an AED. The primary outcome was the AED delivery time by either the bystander or his/her responder.

RESULTS

In total, 61 bystanders were eligible and randomized to either the application group (32) or the control group (29). The 52 with time data were available and analyzed. The AED delivery time by either the bystander or his/her responder was significantly shorter in the application group than in the control group [133.6 (44.4) seconds vs. 202.2 (122.2) seconds, P = 0.01].

CONCLUSIONS

In this simulation-based trial, AED delivery time was shortened by our newly developed smartphone application for the bystander to ask nearby responders to find and bring an AED to the cardiac arrest scene (UMIN-Clinical Trials Registry 000016506).

Differences in implementation strategies of the European Resuscitation Council Guidelines 2015 in Danish hospitals - a nationwide study

Introduction

Guideline implementation is essential to improve survival following cardiac arrest. This study aimed to investigate awareness, expected time frame, and strategy for implementation of the European Resuscitation Council (ERC) Guidelines 2015 in Danish hospitals.

Methods

All public, somatic hospitals with a cardiac arrest team in Denmark were included. A questionnaire was sent to hospital resuscitation committees one week after guideline publication. The questionnaire included questions on awareness of ERC Guidelines 2015 and time frame and strategy for implementation.

Results

In total, 41 hospitals replied (response rate: 87%) between October 22 and December 22, 2015. Overall, 37% hospital resuscitation committees (n=15) were unaware of the guideline content. Most hospitals (80%, n=33) expected completion of guideline implementation within 6 months and 93% hospitals (n=38) expected the staff to act according to the ERC Guidelines 2015 within 6 months. In contrast, 78% hospitals (n=32) expected it would take between 6 months to 3 years for all staff to have completed a resuscitation course based on ERC Guidelines 2015. Overall, 29% hospitals (n=12) planned to have a strategy for implementation later than a month after guideline publication and 10% (n=4) hospitals did not plan to make a strategy.

Conclusion

There are major differences in guideline implementation strategies among Danish hospitals. Many hospital resuscitation committees were unaware of guideline content. Most hospitals expected hospital staff to follow ERC Guidelines 2015 within six months after the publication even though they did not offer information or skill training to all staff members within that time frame.

Video performance-debriefings and ventilation-refreshers improve quality of neonatal resuscitation

AIM

Providers caring for newly born infants require skills and knowledge to initiate prompt and effective positive pressure ventilation (PPV) if the newborn does not breathe spontaneously after birth. We hypothesized implementation of high frequency/short duration deliberate practice training and post event video-based debriefings would improve process of care and decreases time to effective spontaneous respiration.

METHODS

Pre- and post-interventional quality study performed at two Norwegian university hospitals. All newborns receiving PPV were prospectively video-recorded, and initial performance data guided the development of educational interventions. A priori primary outcome was changed from process of care using the Neonatal Resuscitation Performance Evaluation (NRPE) score to time to effective spontaneous respiration as the NRPE score could only be obtained from one site due to lack of staff resources.

RESULTS

Over 12 months, 297 PPV-Refreshers and 52 performance debriefings were completed with 227 unique providers attending a PPV-Refresher and 93 unique providers completed a debriefing. We compared 102 PPV-events pre- to 160 PPV-events post-bundle implementation. The time to effective spontaneous respiration decreased from median (95% confidence interval) 196 (140-237) to 144 (120-163) s, p = 0.010. The NRPE-score increased significantly from median 77% (75-81) pre- to 89% (86-92) post-implementation, p < 0.001. There were no significant differences in time to heart rate >100 beats/min or number of newborns transferred to intensive care.

CONCLUSION

High frequency/short duration deliberate practice PPV psychomotor training combined with performance-focused team debriefings using video recordings of actual resuscitations may improve time to effective spontaneous breathing and adherence to guidelines during real neonatal resuscitations.

The Contribution of Taiwan in International Liaison Committee on Resuscitation Consensus on Science and Treatment Recommendation 2015 (ILCOR CoSTR 2015)

Taiwan has begun its board certification of emergency medicine since 1998. The scholars have also devoted themselves to research in the related fi elds including resuscitation for decades. On the other hand, International Liaison Committee on Resuscitation (ILCOR) was established to build up international expert consensus on resuscitation science in 1992. The National Resuscitation Council of Taiwan (NRCT) is a multidisciplinary organization and becomes one of the founding members of the Resuscitation Council of Asia (RCA) in 2005, whereas the RCA has also become currently the final regional member of ILCOR. Under these international platforms, the experts from Taiwan have significant contributions in establishment of evidence review and clinical guidelines on resuscitation such as ILCOR Consensus on Science and Treatment Recommendation (CoSTR). This brief review will introduce explicitly these important Taiwan investigations cited in ILCOR CoSTR 2015.

Description of hot debriefings after in-hospital cardiac arrests in an international pediatric quality improvement collaborative

BACKGROUND

The American Heart Association recommends debriefing after attempted resuscitation from in-hospital cardiac arrest (IHCA) to improve resuscitation quality and outcomes. This is the first published study detailing the utilization, process and content of hot debriefings after pediatric IHCA.

METHODS

Using prospective data from the Pediatric Resuscitation Quality Collaborative (pediRES-Q), we analyzed data from 227 arrests occurring between February 1, 2016, and August 31, 2017. Hot debriefings, defined as occurring within minutes to hours of IHCA, were evaluated using a modified Team Emergency Assessment Measure framework for qualitative content analysis of debriefing comments.

RESULTS

Hot debriefings were performed following 108 of 227 IHCAs (47%). The median interval to debriefing was 130 min (Interquartile range [IQR] 45, 270). Median debriefing duration was 15 min (IQR 10, 20). Physicians facilitated 95% of debriefings, with a median of 9 participants (IQR 7, 11). After multivariate analysis, accounting for hospital site, debriefing frequency was not associated with patient age, gender, race, illness category or unit type. The most frequent positive (plus) comments involved cooperation/coordination (60%), communication (47%) and clinical standards (41%). The most frequent negative (delta) comments involved equipment (46%), cooperation/coordination (45%), and clinical standards (36%).

CONCLUSION

Approximately half of pediatric IHCAs were followed by hot debriefings. Hot debriefings were multi-disciplinary, timely, and often addressed issues of team cooperation/coordination, communication, clinical standards, and equipment. Additional studies are warranted to identify barriers to hot debriefings and to evaluate the impact of these debriefings on patient outcomes.

ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: A Consensus Statement

Despite significant advances in the field of resuscitation science, important knowledge gaps persist. Current guidelines for resuscitation are based on the International Liaison Committee on Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, which includes treatment recommendations supported by the available evidence. The writing group developed this consensus statement with the goal of focusing future research by addressing the knowledge gaps identified during and after the 2015 International Liaison Committee on Resuscitation evidence evaluation process. Key publications since the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations are referenced, along with known ongoing clinical trials that are likely to affect future guidelines.

Self-learning basic life support: A randomised controlled trial on learning conditions

AIM OF THE STUDY

To investigate whether pure self-learning without instructor support, resulted in the same BLS-competencies as facilitator-led learning, when using the same commercially available video BLS teaching kit.

METHODS

First-year medical students were randomised to either BLS self-learning without supervision or facilitator-led BLS-teaching. Both groups used the MiniAnne kit (Laerdal Medical, Stavanger, Norway) in the students' local language. Directly after the teaching and three months later, all participants were tested on their BLS-competencies in a simulated scenario, using the Resusci Anne SkillReporter™ (Laerdal Medical, Stavanger, Norway). The primary outcome was percentage of correct cardiac compressions three months after the teaching. Secondary outcomes were all other BLS parameters recorded by the SkillReporter and parameters from a BLS-competence rating form.

RESULTS

240 students were assessed at baseline and 152 students participated in the 3-month follow-up. For our primary outcome, the percentage of correct compressions, we found a median of 48% (interquartile range (IQR) 10-83) for facilitator-led learning vs. 42% (IQR 14-81) for self-learning (p = 0.770) directly after the teaching. In the 3-month follow-up, the rate of correct compressions dropped to 28% (IQR 6-59) for facilitator-led learning (p = 0.043) and did not change significantly in the self-learning group (47% (IQR 12-78), p = 0.729).

CONCLUSIONS

Self-learning is not inferior to facilitator-led learning in the short term. Self-learning resulted in a better retention of BLS-skills three months after training compared to facilitator-led training.

Variation in outcome of hospitalised patients with out-of-hospital cardiac arrest from acute coronary syndrome: a cohort study

Background

Each year, approximately 30,000 people have an out-of-hospital cardiac arrest (OHCA) that is treated by UK ambulance services. Across all cases of OHCA, survival to hospital discharge is less than 10%. Acute coronary syndrome (ACS) is a common cause of OHCA.

Objectives

To explore factors that influence survival in patients who initially survive an OHCA attributable to ACS.

Data source

Data collected by the Myocardial Ischaemia National Audit Project (MINAP) between 2003 and 2015.

Participants

Adult patients who had a first OHCA attributable to ACS and who were successfully resuscitated and admitted to hospital.

Main outcome measures

Hospital mortality, neurological outcome at hospital discharge, and time to all-cause mortality.

Methods

We undertook a cohort study using data from the MINAP registry. MINAP is a national audit that collects data on patients admitted to English, Welsh and Northern Irish hospitals with myocardial ischaemia. From the data set, we identified patients who had an OHCA. We used imputation to address data missingness across the data set. We analysed data using multilevel logistic regression to identify modifiable and non-modifiable factors that affect outcome.

Results

Between 2003 and 2015, 1,127,140 patient cases were included in the MINAP data set. Of these, 17,604 OHCA cases met the study inclusion criteria. Overall hospital survival was 71.3%. Across hospitals with at least 60 cases, hospital survival ranged from 34% to 89% (median 71.4%, interquartile range 60.7–76.9%). Modelling, which adjusted for patient and treatment characteristics, could account for only 36.1% of this variability. For the primary outcome, the key modifiable factors associated with reduced mortality were reperfusion treatment [primary percutaneous coronary intervention (pPCI) or thrombolysis] and admission under a cardiologist. Admission to a high-volume cardiac arrest hospital did not influence survival. Sensitivity analyses showed that reperfusion was associated with reduced mortality among patients with a ST elevation myocardial infarction (STEMI), but there was no evidence of a reduction in mortality in patients who did not present with a STEMI.

Limitations

This was an observational study, such that unmeasured confounders may have influenced study findings. Differences in case identification processes at hospitals may contribute to an ascertainment bias.

Conclusions

In OHCA patients who have had a cardiac arrest attributable to ACS, there is evidence of variability in survival between hospitals, which cannot be fully explained by variables captured in the MINAP data set. Our findings provide some support for the current practice of transferring resuscitated patients with a STEMI to a hospital that can deliver pPCI. In contrast, it may be reasonable to transfer patients without a STEMI to the nearest appropriate hospital.

Future work

There is a need for clinical trials to examine the clinical effectiveness and cost-effectiveness of invasive reperfusion strategies in resuscitated OHCA patients of cardiac cause who have not had a STEMI.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

What should be included in the assessment of laypersons' paediatric basic life support skills? Results from a Delphi consensus study

Background

Assessment of laypersons’ Paediatric Basic Life Support (PBLS) skills is important to ensure acquisition of effective PBLS competencies. However limited evidence exists on which PBLS skills are essential for laypersons. The same challenges exist with respect to the assessment of foreign body airway obstruction management (FBAOM) skills. We aimed to establish international consensus on how to assess laypersons’ PBLS and FBAOM skills.

Methods

A Delphi consensus survey was conducted. Out of a total of 84 invited experts, 28 agreed to participate. During the first Delphi round experts suggested items to assess laypersons’ PBLS and FBAOM skills.

In the second round, the suggested items received comments from and were rated by 26 experts (93%) on a 5-point scale (1 = not relevant to 5 = essential). Revised items were anonymously presented in a third round for comments and 23 (82%) experts completed a re-rating. Items with a score above 3 by more than 80% of the experts in the third round were included in an assessment instrument.

Results

In the first round, 19 and 15 items were identified to assess PBLS and FBAOM skills, respectively. The ratings and comments from the last two rounds resulted in nine and eight essential assessment items for PBLS and FBAOM skills, respectively. The PBLS items included: “Responsiveness”,” Call for help”, “Open airway”,” Check breathing”, “Rescue breaths”, “Compressions”, “Ventilations“, “Time factor” and “Use of AED”. The FBAOM items included: “Identify different stages of foreign body airway obstruction”, “Identify consciousness”, “Call for help”, “Back blows“, “Chest thrusts/abdominal thrusts according to age”, “Identify loss of consciousness and change to CPR”, “Assessment of breathing” and “Ventilation”.

Discussion

For assessment of laypersons some PBLS and FBAOM skills described in guidelines are more important than others. Four out of nine of PBLS skills focus on airway and breathing skills, supporting the major importance of these skills for laypersons’ resuscitation attempts.

Conclusions

International consensus on how to assess laypersons’ paediatric basic life support and foreign body airway obstruction management skills was established. The assessment of these skills may help to determine when laypersons have acquired competencies.

Trial registration

Not relevant.

Electronic supplementary material

The online version of this article (10.1186/s13049-018-0474-5) contains supplementary material, which is available to authorized users.

Patient, health service factors and variation in mortality following resuscitated out-of-hospital cardiac arrest in acute coronary syndrome: Analysis of the Myocardial Ischaemia National Audit Project

AIMS

To determine patient and health service factors associated with variation in hospital mortality among resuscitated cases of out-of-hospital cardiac arrest (OHCA) with acute coronary syndrome (ACS).

METHODS

In this cohort study, we used the Myocardial Ischaemia National Audit Project database to study outcomes in patients hospitalised with resuscitated OHCA due to ACS between 2003 and 2015 in the United Kingdom. We analysed variation in inter-hospital mortality and used hierarchical multivariable regression models to examine the association between patient and health service factors with hospital mortality.

RESULTS

We included 17604 patients across 239 hospitals. Overall hospital mortality was 28.7%. In 94 hospitals that contributed at least 60 cases, mortality by hospital ranged from 10.7% to 66.3% (median 28.6%, IQR 23.2% to 39.1%)). Patient and health service factors explained 36.1% of this variation. After adjustment for covariates, factors associated with higher hospital mortality included increasing serum glucose, ST-Elevation myocardial infarction (STEMI) diagnosis, and initial admission to a primary percutaneous coronary intervention (pPCI) capable hospital. Hospital OHCA volume was not associated with mortality. The key modifiable factor associated with lower mortality was early reperfusion therapy in STEMI patients.

CONCLUSION

There was wide variation in inter-hospital mortality following resuscitated OHCA due to ACS that was only partially explained by patient and health service factors. Hospital OHCA volume and pPCI capability were not associated with lower mortality. Early reperfusion therapy was associated with lower mortality in STEMI patients.

The optimal number of personnel for good quality of chest compressions: A prospective randomized parallel manikin trial

BACKGROUND

Long durational chest compression (CC) deteriorates cardiopulmonary resuscitation (CPR) quality. The appropriate number of CC personnel for minimizing rescuer's fatigue is mostly unknown.

OBJECTIVE

We determined the optimal number of personnel needed for 30-min CPR in a rescue-team.

METHODS

We conducted a randomized, manikin trial on healthcare providers. We divided them into Groups A to D according to the assigned different rest period to each group between the 2 min CCs. Groups A, B, C, and D performed CCs at 2, 4, 6, and 8 min rest period. All participants performed CCs for 30 min with a different rest period; participants allocated to Groups A, B, C, and D performed, eight, five, four, and three cycles, respectively. We compared a quality change of CCs among these groups to investigate how the assigned rest period affects the maintenance of CC quality during the 30-min CPR.

RESULTS

This study involved 143 participants (male 58 [41%]; mean age, 24 years,) for the evaluation. As participants had less rest periods, the quality of their CCs such as sufficient depth ratio declined over 30-min CPR. A significant decrease in the sufficient CC depth ratio was observed in the second to the last cycle as compared to the first cycle. (median changes; A: -4%, B: -3%, C: 0%, and D: 0% p < 0.01).

CONCLUSIONS

A 6 min rest period after 2 min CC is vital in order to sustain the quality of CC during a 30-min CPR cycle. At least four personnel may be needed to reduce rescuer's fatigue for a 30-min CPR cycle when the team consists of men and women.

Training in cardiopulmonary resuscitation provided by medical students, residents and specialists: A non-inferiority trial

Introduction:

No definitive answer has been given to the question ‘who should teach cardiopulmonary resuscitation?’ Healthcare professionals and high school teachers are mostly the trainers, but medical students are increasingly being used for this purpose.

Methods:

We divided 296 high school students in three groups based on trainer professional level. Medical students, anaesthesia and intensive care residents, and anaesthesia and intensive care specialists provided basic life support training. We tested their theoretical knowledge with the help of a multiple-choice question questionnaire and practical abilities with the help of a medical simulator, recording chest compression frequency as the primary outcome parameter.

Results:

The study shows comparable results in all groups, with the exception of the chest compression frequency which was higher in the students’ and residents’ groups (students: 134.7/min ± 14.1; residents: 137.9/min ± 15.9; specialists: 126.3/min ± 19.3). Increased rates were not associated with lower depths (39.0 mm ± 8.2, 40.5 mm ± 9.7, and 38.1 mm ± 8.2), so the quality of compressions provided may be seen as equivalent in all the study groups.

Conclusion:

Our data suggest that medical students may be as effective as anaesthesia and intensive care specialists and residents in cardiopulmonary resuscitation training.

Easy-to-learn cardiopulmonary resuscitation training programme: a randomised controlled trial on laypeople's resuscitation performance

INTRODUCTION

Simplifying the learning of cardiopulmonary resuscitation (CPR) is advocated to improve skill acquisition and retention. A simplified CPR training programme focusing on continuous chest compression, with a simple landmark tracing technique, was introduced to laypeople. The study aimed to examine the effectiveness of the simplified CPR training in improving lay rescuers' CPR performance as compared to standard CPR.

METHODS

A total of 85 laypeople (aged 21-60 years) were recruited and randomly assigned to undertake either a two-hour simplified or standard CPR training session. They were tested two months after the training on a simulated cardiac arrest scenario. Participants' performance on the sequence of CPR steps was observed and evaluated using a validated CPR algorithm checklist. The quality of chest compression and ventilation was assessed from the recording manikins.

RESULTS

The simplified CPR group performed significantly better on the CPR algorithm when compared to the standard CPR group (p < 0.01). No significant difference was found between the groups in time taken to initiate CPR. However, a significantly higher number of compressions and proportion of adequate compressions was demonstrated by the simplified group than the standard group (p < 0.01). Hands-off time was significantly shorter in the simplified CPR group than in the standard CPR group (p < 0.001).

CONCLUSION

Simplifying the learning of CPR by focusing on continuous chest compressions, with simple hand placement for chest compression, could lead to better acquisition and retention of CPR algorithms, and better quality of chest compressions than standard CPR.

Education in cardiopulmonary resuscitation in Russia: A systematic review of the available evidence

BACKGROUND

To summarise and appraise cumulative published scientific evidence relevant to cardiopulmonary resuscitation (CPR) education in Russia.

DATA RESOURCES

We searched Medline, Scopus, Science Direct and Russian Science Citation Index databases from December 1991 to December 2016 to identify studies pertaining to the field of CPR education that were carried out by Russian researchers and/or investigated the topic of interest for Russia/Russian population. Reference lists of eligible publications, contents pages of relevant Russian journals and Google Scholar were also searched. There was no limitation based on publication language or study design.

RESULTS

Of 7 964 unique citations identified, 22 studies were included. All studies were published from 2009 to 2016, mainly in Russian. Only three studies were reported to be randomized controlled. Non-medical individuals constituted 17% of studied populations. Most of the studies aimed to assess effects of CPR educational interventions, generally suggesting positive influence of the training conducted. The studies were highly heterogeneous as for methodological approaches, structure and duration of educational interventions, evaluation methods and criteria being used. Methodological quality was generally poor, with >40% publications not passing quality screening and only 2 studies meeting the criteria of moderate high quality.

CONCLUSION

The results suggest paucity, low population coverage, high thematic and methodological heterogeneity and low quality of the studies addressing CPR education, which were carried out in the Russian Federation. There is a critical need in conducting methodologically consistent, large-scale, randomized, controlled studies evaluating and comparing efficiency of educational interventions for teaching CPR in different population categories of Russia.

2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary

The International Liaison Committee on Resuscitation has initiated a near-continuous review of cardiopulmonary resuscitation science that replaces the previous 5-year cyclic batch-and-queue approach process. This is the first of an annual series of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations summary articles that will include the cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation in the previous year. The review this year includes 5 basic life support and 1 pediatric Consensuses on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Each of these includes a summary of the science and its quality based on Grading of Recommendations, Assessment, Development, and Evaluation criteria and treatment recommendations. Insights into the deliberations of the International Liaison Committee on Resuscitation task force members are provided in Values and Preferences sections. Finally, the task force members have prioritized and listed the top 3 knowledge gaps for each population, intervention, comparator, and outcome question.

The International Liaison Committee on Resuscitation-Review of the last 25 years and vision for the future

2017 marks the 25th anniversary of the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1992 to create a forum for collaboration among principal resuscitation councils worldwide. Since then, ILCOR has established and distinguished itself for its pioneering vision and leadership in resuscitation science. By systematically assessing the evidence for resuscitation standards and guidelines and by identifying national and regional differences, ILCOR reached consensus on international resuscitation guidelines in 2000, and on international science and treatment recommendations in 2005, 2010 and 2015. However, local variation and contextualization of guidelines are evident by subtle differences in regional and national resuscitation guidelines. ILCOR's efforts to date have enhanced international cooperation, and progressively more transparent and systematic collection and analysis of pertinent scientific evidence. Going forward, this sets the stage for ILCOR to pursue its vision to save more lives globally through resuscitation.

Paediatric cardiopulmonary resuscitation training program in Latin-America: the RIBEPCI experience

BACKGROUND

To describe the design and to present the results of a paediatric and neonatal cardiopulmonary resuscitation (CPR) training program adapted to Latin-America.

METHODS

A paediatric CPR coordinated training project was set up in several Latin-American countries with the instructional and scientific support of the Spanish Group for Paediatric and Neonatal CPR. The program was divided into four phases: CPR training and preparation of instructors; training for instructors; supervised teaching; and independent teaching. Instructors from each country participated in the development of the next group in the following country. Paediatric Basic Life Support (BLS), Paediatric Intermediate (ILS) and Paediatric Advanced (ALS) courses were organized in each country adapted to local characteristics.

RESULTS

Five Paediatric Resuscitation groups were created sequentially in Honduras (2), Guatemala, Dominican Republican and Mexico. During 5 years, 6 instructors courses (94 students), 64 Paediatric BLS Courses (1409 students), 29 Paediatrics ILS courses (626 students) and 89 Paediatric ALS courses (1804 students) were given. At the end of the program all five groups are autonomous and organize their own instructor courses.

CONCLUSIONS

Training of autonomous Paediatric CPR groups with the collaboration and scientific assessment of an expert group is a good model program to develop Paediatric CPR training in low- and middle income countries. Participation of groups of different countries in the educational activities is an important method to establish a cooperation network.

Incorporating cardiopulmonary resuscitation training into a cardiac rehabilitation programme: A feasibility study

Background:

Patients with a cardiac history are at future risk of cardiac events, including out-of-hospital cardiac arrest. Targeting cardiopulmonary resuscitation (CPR) training to family members of cardiac patients has long been advocated, but is an area in need of contemporary research evidence. An environment yet to be investigated for targeted training is cardiac rehabilitation.

Aim:

To evaluate the feasibility of providing CPR training in a cardiac rehabilitation programme among patients, their family members and staff.

Methods:

A prospective before and after study design was used. CPR training was delivered using video self-instruction CPR training kits, facilitated by a cardiac nurse. Data was collected pre-training, post-training and at one month.

Results:

Cardiac patient participation rates in CPR classes were high ( n = 56, 72.7% of eligible patients) with a further 27 family members attending training. Patients were predominantly male (60.2%), family members were predominantly female (81.5%), both with a mean age of 65 years. Confidence to perform CPR and willingness to use skills significantly increased post-training (both p<0.001). Post training participants demonstrated a mean compression rate of 112 beats/min and a mean depth of 48 mm. Training reach was doubled as participants shared the video self-instruction kit with a further 87 people. Patients, family members and cardiac rehabilitation staff had positive feedback about the training.

Conclusions:

We demonstrated that cardiac rehabilitation is an effective and feasible environment to provide CPR training. Using video self-instruction CPR training kits enabled further training reach to the target population.

Basic Cardiac Life Support: 2016 Singapore Guidelines

Basic Cardiac Life Support (BCLS) or cardiopulmonary resuscitation (CPR) refers to the skills required (without use of equipment) in the resuscitation of cardiac arrest individuals. On recognising cardiac arrest, chest compressions should be initiated. Good quality compressions are with arms extended, elbows locked, shoulders directly over the casualty's chest and heel of the palm on the lower half of the sternum. The rescuer pushes hard and fast, compressing 4-6 cm deep for adults at 100-120 compressions per minute with complete chest recoil. Two quick mouth-to-mouth ventilations (each 400-600 mL tidal volume) should be delivered after every 30 chest compressions. Chest compression-only CPR is recommended for lay rescuers, dispatcher-assisted CPR and those unable or unwilling to give ventilations. CPR should be stopped when the casualty wakes up, an emergency team takes over casualty care or if an automated external defibrillator prompts for analysis of heart rhythm or delivery of shock.

The implementation of cardiac arrest treatment recommendations in English acute NHS trusts: a national survey

PURPOSE OF THE STUDY

There are approximately 35 000 in-hospital cardiac arrests in the UK each year. Successful resuscitation requires integration of the medical science, training and education of clinicians and implementation of best practice in the clinical setting. In 2015, the International Liaison Committee on Resuscitation (ILCOR) published its latest resuscitation treatment recommendations. It is currently unknown the extent to which these treatment recommendations have been successfully implemented in practice in English NHS acute hospital trusts.

METHODS

We conducted an electronic survey of English acute NHS trusts to assess the implementation of key ILCOR resuscitation treatment recommendations in relation to in-hospital cardiac arrest practice at English NHS acute hospital trusts.

RESULTS

Of 137 eligible trusts, 73 responded to the survey (response rate 53.3%). The survey identified significant variation in the implementation of ILCOR recommendations. In particular, the use of waveform capnography (n=33, 45.2%) and ultrasound (n=29, 39.7%) was often reported to be available only in specialist areas. Post-resuscitation debriefing occurs following every in-hospital cardiac arrest in few trusts (5.5%, n=4), despite a strong ILCOR recommendation. In contrast, participation in a range of quality improvement strategies such as the National Cardiac Arrest Audit (90.4%, n=66) and resuscitation equipment provision/audit (91.8%, n=67) were high. Financial restrictions were identified by 65.8% (n=48) as the main barrier to guideline implementation.

CONCLUSION

Our survey found that ILCOR treatment recommendations had not been fully implemented in most English NHS acute hospital trusts. Further work is required to better understand barriers to implementation.

Intensive care medicine research agenda on cardiac arrest

Over the last 15 years, treatment of comatose post-cardiac arrest patients has evolved to include therapeutic strategies such as urgent coronary angiography with percutaneous coronary intervention (PCI), targeted temperature management (TTM)-requiring mechanical ventilation and sedation-and more sophisticated and cautious prognostication. In 2015, collaboration between the European Resuscitation Council (ERC) and the European Society for Intensive Care Medicine (ESICM) resulted in the first European guidelines on post-resuscitation care. This review addresses the major recent advances in the treatment of cardiac arrest, recent trials that have challenged current practice and the remaining areas of uncertainty.

Lay persons alerted by mobile application system initiate earlier cardio-pulmonary resuscitation: A comparison with SMS-based system notification

AIM

We compared the time to initiation of cardiopulmonary resuscitation (CPR) by lay responders and/or first responders alerted either via Short Message Service (SMS) or by using a mobile application-based alert system (APP).

METHODS

The Ticino Registry of Cardiac Arrest collects all data about out-of-hospital cardiac arrests (OHCAs) occurring in the Canton of Ticino. At the time of a bystander's call, the EMS dispatcher sends one ambulance and alerts the first-responders network made up of police officers or fire brigade equipped with an automatic external defibrillator, the so called "traditional" first responders, and - if the scene was considered safe - lay responders as well. We evaluated the time from call to arrival of traditional first responders and/or lay responders when alerted either via SMS or the new developed mobile APP.

RESULTS

Over the study period 593 OHCAs have occurred. Notification to the first responders network was sent via SMS in 198 cases and via mobile APP in 134 cases. Median time to first responder/lay responder arrival on scene was significantly reduced by the APP-based system (3.5 [2.8-5.2]) compared to the SMS-based system (5.6 [4.2-8.5] min, p 0.0001). The proportion of lay responders arriving first on the scene significantly increased (70% vs. 15%, p<0.01) with the APP. Earlier arrival of a first responder or of a lay responder determined a higher survival rate.

CONCLUSIONS

The mobile APP system is highly efficient in the recruitment of first responders, significantly reducing the time to the initiation of CPR thus increasing survival rates.

Accuracy of Postresuscitation Team Debriefings in a Pediatric Emergency Department

STUDY OBJECTIVE

Guideline committees recommend postresuscitation debriefings to improve performance. "Hot" postresuscitation debriefings occur immediately after the event and rely on team recall. We assessed the ability of resuscitation teams to recall their performance in team-based, hot debriefings in a pediatric emergency department (ED), using video review as the criterion standard. We hypothesized that debriefing accuracy will improve during the course of the study.

METHODS

Resuscitation physician and nurse leaders cofacilitated debriefings after ED resuscitations involving cardiopulmonary resuscitation (CPR) or intubation. Debriefing teams recorded their self-assessments of clinical performance measures with standardized debriefing forms. The debriefing form data were compared with actual performance measured by video review at 2 pediatric EDs over 22 months. CPR performance measures included time to automated external defibrillator pad placement, epinephrine administration timing, and compression pause timing. Intubation measures included occurrences of oxygen desaturation, number of intubation attempts, and use of end-tidal carbon dioxide monitoring.

RESULTS

We analyzed 100 resuscitations (14 cardiac arrests, 22 cardiac arrests with intubation, and 64 intubations). The accuracy of debriefing answers was 87%, increasing from 83% to 91% between the first and second halves of the study period (7.7% difference; 95% confidence interval 0.2% to 15%). Debriefings that acknowledged an error in certain performance measures (ie, automated external defibrillator pad placement delay, multiple intubation attempts, and occurrence of oxygen desaturation) had significantly worse performance in those specific measures on video review.

CONCLUSION

Teams in postresuscitation debriefings had a higher degree of debriefing answer accuracy in the final 50 debriefings than in the first 50. Teams also distinguished various degrees of resuscitation performance.

e-Learning in Advanced Life Support-What factors influence assessment outcome?

AIM

To establish variables which are associated with favourable Advanced Life Support (ALS) course assessment outcomes, maximising learning effect.

METHOD

Between 1 January 2013 and 30 June 2014, 8218 individuals participated in a Resuscitation Council (UK) e-learning Advanced Life Support (e-ALS) course. Participants completed 5-8h of online e-learning prior to attending a one day face-to-face course. e-Learning access data were collected through the Learning Management System (LMS). All participants were assessed by a multiple choice questionnaire (MCQ) before and after the face-to-face aspect alongside a practical cardiac arrest simulation (CAS-Test). Participant demographics and assessment outcomes were analysed.

RESULTS

The mean post e-learning MCQ score was 83.7 (SD 7.3) and the mean post-course MCQ score was 87.7 (SD 7.9). The first attempt CAS-Test pass rate was 84.6% and overall pass rate 96.6%. Participants with previous ALS experience, ILS experience, or who were a core member of the resuscitation team performed better in the post-course MCQ, CAS-Test and overall assessment. Median time spent on the e-learning was 5.2h (IQR 3.7-7.1). There was a large range in the degree of access to e-learning content. Increased time spent accessing e-learning had no effect on the overall result (OR 0.98, P=0.367) on simulated learning outcome.

CONCLUSION

Clinical experience through membership of cardiac arrest teams and previous ILS or ALS training were independent predictors of performance on the ALS course whilst time spent accessing e-learning materials did not affect course outcomes. This supports the blended approach to e-ALS which allows participants to tailor their e-learning experience to their specific needs.

Paramedic resuscitation competency: A survey of Australian and New Zealand emergency medical services

OBJECTIVE

We have previously established that paramedic exposure to out-of-hospital cardiac arrest (OHCA) is relatively rare, therefore clinical exposure cannot be relied on to maintain resuscitation competency. We aimed to identify the current practices within emergency medical services (EMS) for developing and maintaining paramedic resuscitation competency.

METHODS

We developed and conducted an online cross-sectional survey of Australian and New Zealand EMS in 2015. The survey was piloted by one EMS and targeted at education managers.

RESULTS

A total of nine of the 10 EMS responded to the survey. All EMS reported that they provide resuscitation training to paramedics at the commencement of their employment (median 16 h, interquartile range [IQR]: 7-80). With the exception of one EMS that did not provide any refresher training, a median of 4 h (IQR: 1-7) resuscitation training was provided to paramedics annually. All EMS used cardiac arrest simulations and skill stations to train paramedics. Paramedic exposure to OHCA was not taken into account to determine their training needs. Resuscitation competency was tested by EMS: annually (3/9), biennially (4/9) or not at all (2/9). Two EMS used CPR-feedback devices in clinical practice and only one EMS regularly performed formal debriefing after OHCA cases. Barriers to resuscitation competency included: difficulty removing paramedics from clinical duties for training and a lack of paramedic exposure to OHCA.

CONCLUSION

All of the surveyed EMS provided initial resuscitation training to paramedics, but competency testing and refresher training practices varied between services. A lack of individual exposure to cardiac arrest and training time were identified as barriers to resuscitation competency.