Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

The use of high-fidelity manikins for advanced life support training--A systematic review and meta-analysis

OBJECTIVES

The objective of this study was to evaluate the effectiveness of high versus low fidelity manikins in the context of advanced life support training for improving knowledge, skill performance at course conclusion, skill performance between course conclusion and one year, skill performance at one year, skill performance in actual resuscitations, and patient outcomes.

METHODS

A systematic search of Pubmed, Embase and Cochrane databases was conducted through January 31, 2014. We included two-group non-randomized and randomized studies in any language comparing high versus low fidelity manikins for advanced life support training. Reviewers worked in duplicate to extract data on learners, study design, and outcomes. The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to evaluate the overall quality of evidence for each outcome.

RESULTS

3840 papers were identified from the literature search of which 14 were included (13 randomized controlled trials; 1 non-randomized controlled trial). Meta-analysis of studies reporting skill performance at course conclusion demonstrated a moderate benefit for high fidelity manikins when compared with low fidelity manikins [Standardized Mean Difference 0.59; 95% CI 0.13-1.05]. Studies measuring skill performance at one year, skill performance between course conclusion and one year, and knowledge demonstrated no significant benefit for high fidelity manikins.

CONCLUSION

The use of high fidelity manikins for advanced life support training is associated with moderate benefits for improving skills performance at course conclusion. Future research should define the optimal means of tailoring fidelity to enhance short and long term educational goals and clinical outcomes.

A description of communication patterns during CPR in ICU

BACKGROUND

Deficiencies in communication in health care are a common source of medical error. Preferred communication patterns are a component of resuscitation teaching. We audio-recorded resuscitations in a mixed paediatric medical and surgical ICU to describe communication.

METHODS

In the intensive care unit, resuscitation events were prospectively audio-recorded by two trained observers (using handheld recorders). Recordings were transcribed and anonymised within 24h. We grouped utterances regarding the same subject matter from beginning (irrespective of response) as a communication epoch. For each epoch, we describe the initiator, audience and content of message. Teamwork behaviours were described using Anesthesia Nontechnical Skills framework (ANTS), a behavioural marker system for crisis-resource management.

RESULTS

Consent rates from staff were 139/140 (99%) and parents were 67/92 (73%). We analysed 36min 57s of audio dialogue from 4 cardiac arrest events in 363h of prospective screening. There were 180 communication epochs (1 every 12s): 100 (56%) from the team-leader and 80 (44%) from non-team-leader(s). Team-leader epochs were to give or confirm orders or assert authority (61%), clarify patient history (14%) and provide clinical updates (25%). Non-team-leader epochs were more often directed to the team (65%) than the team-leader (35%). Audio-recordings provided information for 80% of the ANTS component elements with scores of 2-4.

CONCLUSION

Communication epochs were frequent, most from the team-leader. We identified an 'outer loop' of communication between team members not including the team-leader, responsible for 44% of all communication events. We discuss difficulties in this research methodology. Future work includes exploring the process of the 'outer loop' by resuscitation team members to evaluate the optimal balance between single leader and team suggestions, the content of the outer loop discussions and in-event communication strategies to improve outcomes.

Team-training in healthcare: a narrative synthesis of the literature

BACKGROUND

Patients are safer and receive higher quality care when providers work as a highly effective team. Investment in optimising healthcare teamwork has swelled in the last 10 years. Consequently, evidence regarding the effectiveness for these interventions has also grown rapidly. We provide an updated review concerning the current state of team-training science and practice in acute care settings.

METHODS

A PubMed search for review articles examining team-training interventions in acute care settings published between 2000 and 2012 was conducted. Following identification of relevant reviews with searches terminating in 2008 and 2010, PubMed and PSNet were searched for additional primary studies published in 2011 and 2012. Primary outcomes included patient outcomes and quality indices. Secondary outcomes included teamwork behaviours, knowledge and attitudes.

RESULTS

Both simulation and classroom-based team-training interventions can improve teamwork processes (eg, communication, coordination and cooperation), and implementation has been associated with improvements in patient safety outcomes. Thirteen studies published between 2011 and 2012 reported statistically significant changes in teamwork behaviours, processes or emergent states and 10 reported significant improvement in clinical care processes or patient outcomes, including mortality and morbidity. Effects were reported across a range of clinical contexts. Larger effect sizes were reported for bundled team-training interventions that included tools and organisational changes to support sustainment and transfer of teamwork competencies into daily practice.

CONCLUSIONS

Overall, moderate-to-high-quality evidence suggests team-training can positively impact healthcare team processes and patient outcomes. Additionally, toolkits are available to support intervention development and implementation. Evidence suggests bundled team-training interventions and implementation strategies that embed effective teamwork as a foundation for other improvement efforts may offer greatest impact on patient outcomes.

Utility and assessment of non-technical skills for rapid response systems and medical emergency teams

Efforts are ongoing to improve outcomes from cardiac arrest and medical emergencies. A promising quality improvement modality is use of non-technical skills (NTS) that aim to address human factors through improvements in performance of leadership, communication, situational awareness and decision-making. Originating in the airline industry, NTS training has been successfully introduced into anaesthesia, surgery, emergency medicine and other acute medical specialities. Some aspects of NTS have already achieved acceptance for cardiac arrest teams. Leadership skills are emphasised in advanced life support training and have shown favourable results when employed in simulated and clinical resuscitation scenarios. The application of NTS in medical emergency teams as part of a rapid response system attending medical emergencies is less certain; however, observations of simulations have also shown promise. This review highlights the potential benefits of NTS competency for cardiac arrest teams and, more importantly, medical emergency teams because of the diversity of clinical scenarios encountered. Discussion covers methods to assess and refine NTS and NTS training to optimise performance in the clinical environment. Increasing attention should be applied to yielding meaningful patient and organisational outcomes from use of NTS. Similarly, implementation of any training course should receive appropriate scrutiny to refine team and institutional performance.

Cardiac arrest teams and medical emergency teams in Finland: a nationwide cross-sectional postal survey

BACKGROUND

The implementation, characteristics and utilisation of cardiac arrest teams (CATs) and medical emergency teams (METs) in Finland are unknown. We aimed to evaluate how guidelines on advanced in-hospital resuscitation have been translated to practice.

METHODS

A cross-sectional postal survey including all public hospitals providing anaesthetic services.

RESULTS

Of the 55 hospitals, 51 (93%) participated in the study. All hospitals with intensive care units (university and central hospitals, n = 24) took part. In total, 88% of these hospitals (21/24) and 30% (8/27) of the small hospitals had CATs. Most hospitals with CATs (24/29) recorded team activations. A structured debriefing after a resuscitation attempt was organised in only one hospital. The median incidence of in-hospital cardiac arrest in Finland was 1.48 (Q1 = 0.93, Q3 = 1.93) per 1000 hospital admissions. METs had been implemented in 31% (16/51) of the hospitals. A physician participated in MET activation automatically in half (8/16) of the teams. Operating theatres (13/16), emergency departments (10/16) and paediatric wards (7/16) were the most common sites excluded from the METs' operational areas. The activation thresholds for vital signs varied between hospitals. The lower upper activation threshold for respiratory rate was associated with a higher MET activation rate. The national median MET activation rate was 2.3 (1.5, 4.8) per 1000 hospital admissions and 1.5 (0.96, 4.0) per every cardiac arrest.

CONCLUSIONS

Current guidelines emphasise the preventative actions on in-hospital cardiac arrest. Practices are changing accordingly but are still suboptimal especially in central and district hospitals. Unified guidelines on rapid response systems are required.

A randomized trial comparing two intraosseous access devices in intrahospital healthcare providers with a focus on retention of knowledge, skill, and self-efficacy

INTRODUCTION

Intraosseous access is recommended in vitally compromised patients if an intravenous access cannot be easily obtained. Intraosseous infusion can be initiated by various healthcare providers. Currently, there are two mechanical intraosseous devices approved by the U.S. Food and Drug Administration (FDA) for use in adults and children. A comparison is made in this study of the theoretical and practical performance by anesthesiologists and registered nurses of anesthesia (RNAs) in the use of the battery-powered device (device A) versus the spring-loaded needle device (device B). This study entailed a 12-month follow-up of knowledge, skill retention, and self-efficacy measured by standardized testing.

METHODS

A prospective randomized trial was performed, initially comparing 15 anesthesiologists and 15 RNAs, both on using the two types of intraosseous devices. A structured lecture and skill station was given with the educational aids provided by the respective manufacturers. Individual knowledge and practical skills were tested at 0, 3, and 12 months after the initial course.

RESULTS

There was no statistical significant difference in the retention of theoretical knowledge between RNAs and anesthesiologists on all testing occasions. However, the self-efficacy of the anesthesiologists is significantly higher (p < 0.01) than the self-efficacy of the RNAs for both devices, on any testing occasion. Insufficient skills were local disinfection (both groups, both devices) and attachment of the needle to the intravenous line (RNAs with both devices). In 33 % of all device B handlings, unsafe practice occurred.

CONCLUSION

The use of device A is safer in handling in comparison to device B at 12 months follow-up. The hypothesis that doctors are more qualified in obtaining intraosseous access has been disproven, as anesthesiologists were as successful as RNAs. However, the low self-efficacy of RNAs in the use of intraosseous devices could diminish the chance of them actually using one.

Development of a first-responder dispatch system using a smartphone

We constructed a prototype community first responder (CFR) dispatch system. The system sends incident information, including a map, to the chosen CFR's mobile phone. We tested it in a simulation of 30 out-of-hospital cardiac arrest incidents which had occurred in the town of Motegi during the previous year. Thirty off-duty firefighters acted as CFRs and were sent to the same locations. The mean response time (from the CFR receiving dispatch information to arrival at the scene) was 3 min 37s faster than the actual response time in the corresponding historical control, i.e. the response time was reduced by 36% (P < 0.01). The median travel distance of the CFRs was 3.4 km and there was a positive correlation between response time and travel distance. The study showed that interactive communication between dispatcher and CFR was important for effective operation and that CFRs could reach an OHCA patient before the Emergency Medical Service arrives.

Spaced scenario demonstrations improve knowledge and confidence in pediatric acute illness management

OBJECTIVES

Nationally accredited simulation courses such as advance pediatric life support and pediatric advance life support are recommended for health care professionals (HCPs) at two yearly intervals as a minimum requirement, despite literature evidence suggesting rapid decline in knowledge shortly after course completion. The objective of this study was to evaluate an observation-based, educational intervention program aimed at improving previously acquired knowledge and confidence in managing critical illnesses.

METHODS

A prospective cohort longitudinal study was conducted over a 6-month period. Participants were assessed with a knowledge based questionnaire immediately prior to and after observing 12 fortnightly critical illness scenario demonstrations (CISDs). The outcome measure was performance on questionnaires. Regression analysis was used to adjust for potential confounders. Questionnaire practice effect was evaluated on 30 independent HCPs not exposed to the CISDs.

RESULTS

Fifty-four HCPs (40 doctors and 14 nurses) participated in the study. All participants had previously attended nationally accredited simulation courses with a mean time since last attendance of 1.8 ± 0.4 years. The median number of attendances at CISD was 6 (2-12). The mean questionnaire scores at baseline (17.2/25) were significantly lower than the mean post intervention questionnaire scores (20.3/25), p = 0.003. The HCPs self-rated confidence in managing CISD was 6.5 times higher at the end of the program in the intervention group (p = 0.002) than at baseline. There was no practice effect for questionnaires demonstrated in the independent sample.

CONCLUSION

The educational intervention program significantly improved the knowledge and confidence of the participants in managing pediatric critical illnesses. The CISD program provides an inexpensive, practical, and time effective method of facilitating knowledge acquisition and retention. Despite the distinctively different approach, this study has shown the effectiveness of the participant being an observer to enhance pediatric resuscitation skills.

The Effect of Computer-Based Resuscitation Simulation on Nursing Students’ Performance, Self-Efficacy, Post-Code Stress, and Satisfaction

Computer-based simulation has intuitive appeal to both educators and learners with the flexibility of time, place, immediate feedback, and self-paced and consistent curriculum. The purpose of this study was to assess the effects of computer-based simulation on nursing students’ performance, self-efficacy, post-code stress, and satisfaction between computer-based simulation plus instructor-led cardiopulmonary resuscitation training group and instructor-led resuscitation training-only group. This study was a nonequivalent control group posttest-only design. There were 213 second year nursing students randomly assigned to one of two groups: 109 nursing students with computer-based simulation or 104 with control group. Overall nursing students’ performance score was higher in the computer-based simulation group than in the control group but reached no statistical significance (t = 1.086, p = .283). There were no significant differences in resuscitation-specific self-efficacy, post-code stress, and satisfaction between the two groups. Computer-based simulation combined with hands-on practice did not affect in nursing students’ performance, self-efficacy, post-code stress, and satisfaction in nursing students. Further study must be conducted to inform instructional design and help integrate computer-based simulation and rigorous scoring rubrics.

Factors predicting the use of therapeutic hypothermia and survival in unconscious out-of-hospital cardiac arrest patients admitted to the ICU

INTRODUCTION

Therapeutic hypothermia (TH) after out-of-hospital cardiac arrest (OHCA) was adopted early in Norway. Since 2004 the general recommendation has been to cool all unconscious OHCA patients treated in the intensive care unit (ICU), but the decision to cool individual patients was left to the responsible physician. We assessed factors that were associated with use of TH and predicted survival.

METHOD

We conducted a retrospective observational study of prospectively collected cardiac arrest and ICU registry data from 2004 to 2008 at three university hospitals.

RESULTS

A total of 715 unconscious patients older than 18 years of age, who suffered OHCA of both cardiac and non-cardiac causes, were included. With an overall TH use of 70%, the survival to discharge was 42%, with 90% of the survivors having a favourable cerebral outcome. Known positive prognostic factors such as witnessed arrest, bystander cardio pulmonary resuscitation (CPR), shockable rhythm and cardiac origin were all positive predictors of TH use and survival. On the other side, increasing age predicted a lower utilisation of TH: Odds Ratio (OR), 0.96 (95% CI, 0.94 to 0.97); as well as a lower survival: OR 0.96 (95% CI, 0.94 to 0.97). Female gender was also associated with a lower use of TH: OR 0.65 (95% CI, 0.43 to 0.97); and a poorer survival: OR 0.57 (95% CI, 0.36 to 0.92). After correcting for other prognostic factors, use of TH remained an independent predictor of improved survival with OR 1.91 (95% CI 1.18-3.06; P <0.001). Analysing subgroups divided after initial rhythm, these effects remained unchanged for patients with shockable rhythm, but not for patients with non-shockable rhythm where use of TH and female gender lost their predictive value.

CONCLUSIONS

Although TH was used in the majority of unconscious OHCA patients admitted to the ICU, actual use varied significantly between subgroups. Increasing age predicted both a decreased utilisation of TH as well as lower survival. Further, in patients with a shockable rhythm female gender predicted both a lower use of TH and poorer survival. Our results indicate an underutilisation of TH in some subgroups. Hence, more research on factors affecting TH use and the associated outcomes in subgroups of post-resuscitation patients is needed.

A survey of nurses' perceived competence and educational needs in performing resuscitation

BACKGROUND

Effective training is needed for high-quality performance of staff nurses, who are often the first responders in initiating resuscitation. There is insufficient evidence to identify specific educational strategies that improve outcomes, including early recognition and rescue of the critical patient. This study was conducted to identify perceived competence and educational needs as well as to examine factors influencing perceived competence in resuscitation among staff nurses to build a resuscitation training curriculum.

METHODS

A convenience sample of 502 staff nurses was recruited from 11 hospitals in a single city. Staff nurses were asked to complete a self-administered questionnaire.

RESULTS

On a five-point scale, chest compression was the lowest-rated technical skill (M = 3.33, SD = 0.80), whereas staying calm and focusing on required tasks was the lowest-rated non-technical skill (M = 3.30, SD = 0.80). Work duration, the usefulness of simulation, recent code experience, and recent simulation-based training were significant factors in perceived competence, F(4, 496) = 45.94, p < .001. Simulation-based resuscitation training was the most preferred training modality, and cardiac arrest was the most preferred training topic.

CONCLUSION

Based on this needs assessment, a simulation-based resuscitation training curriculum with cardiac arrest scenarios is suggested to improve the resuscitation skills of staff nurses.

A structured educational intervention to improve targeted temperature management utilization after cardiac arrest

PURPOSE

Post-arrest targeted temperature management (TTM) has been shown to dramatically improve outcomes after resuscitation, yet studies have revealed inconsistent and slow adoption. Little is known about barriers to TTM implementation and methods to increase adoption. We hypothesized that a structured educational intervention might increase TTM use.

MATERIALS AND METHODS

Subjects participated in mixed quantitative/qualitative surveys before and after attending a series of TTM educational courses from October 2010 to October 2011, to determine usage and barriers to implementation. A knowledge examination was also administered to participants before and after the course.

RESULTS

Clinicians completed 227 surveys (129 pre-training and 98 post-training) and 343 exams (165 pre-training and 178 post-training). A ranking survey (score range 1-7; 7 as most challenging) found that communication challenges (mean score 4.7 ± 1.5) and lacking adequate education (4.3 ± 1.9) were the 2 most emphasized barriers to implementation. Post-survey results found that 95% (93/98) of respondents felt more confident initiating TTM post-intervention. There was a statistically significant increase in self-reported TTM usage after participation in the program (P < .01).

CONCLUSIONS

A focused TTM program led to increased confidence and usage among participants. Future work will focus on targeted training to address specific barriers and increase TTM utilization.

Effects of pre-training using serious game technology on CPR performance--an exploratory quasi-experimental transfer study

BACKGROUND

Multiplayer virtual world (MVW) technology creates opportunities to practice medical procedures and team interactions using serious game software. This study aims to explore medical students' retention of knowledge and skills as well as their proficiency gain after pre-training using a MVW with avatars for cardio-pulmonary resuscitation (CPR) team training.

METHODS

Three groups of pre-clinical medical students, n = 30, were assessed and further trained using a high fidelity full-scale medical simulator: Two groups were pre-trained 6 and 18 months before assessment. A reference control group consisting of matched peers had no MVW pre-training. The groups consisted of 8, 12 and 10 subjects, respectively. The session started and ended with assessment scenarios, with 3 training scenarios in between. All scenarios were video-recorded for analysis of CPR performance.

RESULTS

The 6 months group displayed greater CPR-related knowledge than the control group, 93 (±11)% compared to 65 (±28)% (p < 0.05), the 18 months group scored in between (73 (±23)%).At start the pre-trained groups adhered better to guidelines than the control group; mean violations 0.2 (±0.5), 1.5 (±1.0) and 4.5 (±1.0) for the 6 months, 18 months and control group respectively. Likewise, in the 6 months group no chest compression cycles were delivered at incorrect frequencies whereas 54 (±44)% in the control group (p < 0.05) and 44 (±49)% in 18 months group where incorrectly paced; differences that disappeared during training.

CONCLUSIONS

This study supports the beneficial effects of MVW-CPR team training with avatars as a method for pre-training, or repetitive training, on CPR-skills among medical students.

Decoding twitter: Surveillance and trends for cardiac arrest and resuscitation communication

AIM OF THE STUDY

Twitter has over 500 million subscribers but little is known about how it is used to communicate health information. We sought to characterize how Twitter users seek and share information related to cardiac arrest, a time-sensitive cardiovascular condition where initial treatment often relies on public knowledge and response.

METHODS

Tweets published April-May 2011 with keywords cardiac arrest, CPR, AED, resuscitation, heart arrest, sudden death and defib were identified. Tweets were characterized by content, dissemination, and temporal trends. Tweet authors were further characterized by: self-identified background, tweet volume, and followers.

RESULTS

Of 62,163 tweets (15,324, 25%) included resuscitation/cardiac arrest-specific information. These tweets referenced specific cardiac arrest events (1130, 7%), CPR performance or AED use (6896, 44%), resuscitation-related education, research, or news media (7449, 48%), or specific questions about cardiac arrest/resuscitation (270, 2%). Regarding dissemination (1980, 13%) of messages were retweeted. Resuscitation specific tweets primarily occurred on weekdays. Most users (10,282, 93%) contributed three or fewer tweets during the study time frame. Users with more than 15 resuscitation-specific tweets in the study time frame had a mean 1787 followers and most self-identified as having a healthcare affiliation.

CONCLUSION

Despite a large volume of tweets, Twitter can be filtered to identify public knowledge and information seeking and sharing about cardiac arrest. To better engage via social media, healthcare providers can distil tweets by user, content, temporal trends, and message dissemination. Further understanding of information shared by the public in this forum could suggest new approaches for improving resuscitation related education.

The effect of the AED and AED programs on survival of individuals, groups and populations

OBJECTIVE

The automated external defibrillator (AED) is a tool that contributes to survival with mixed outcomes. This review assesses the effectiveness of the AED, consistencies and variations among studies, and how varying outcomes can be resolved.

METHODS

A worksheet for the International Liaison Committee on Resuscitation (ILCOR) 2010 science review focused on hospital survival in AED programs was the foundation of the articles reviewed. Articles identified in the search covering a broader range of topics were added. All articles were read by at least two authors; consensus discussions resolved differences.

RESULTS

AED use developed sequentially. Use of AEDs by emergency medical technicians (EMTs) compared to manual defibrillators showed equal or superior survival. AED use was extended to trained responders likely to be near victims, such as fire/rescue, police, airline attendants, and casino security guards, with improvement in all venues but not all programs. Broad public access initiatives demonstrated increased survival despite low rates of AED use. Home AED programs have not improved survival; in-hospital trials have had mixed results. Successful programs have placed devices in high-risk sites, maintained the AEDs, recruited a team with a duty to respond, and conducted ongoing assessment of the program.

CONCLUSION

The AED can affect survival among patients with sudden ventricular fibrillation (VF). Components of AED programs that affect outcome include the operator, location, the emergency response system, ongoing maintenance and evaluation. Comparing outcomes is complicated by variations in definitions of populations and variables. The effect of AEDs on individuals can be dramatic, but the effect on populations is limited.

Current termination of resuscitation (TOR) guidelines predict neurologically favorable outcome in Japan

BACKGROUND

It is unclear whether the basic life support (BLS) and advanced life support (ALS) pre-hospital termination of resuscitation (TOR) rules developed in North America can be applied successfully to patients with out-of-hospital cardiac arrest (OHCA) in other countries.

OBJECTIVES

To assess the performance of the BLS and ALS TOR in Japan.

METHODS

Retrospective nationwide, population-based, observational cohort study of consecutive OHCA patients with emergency responder resuscitation attempts from 1 January 2005 to 31 December 2009 in Japan. The BLS TOR rule has 3 criteria whereas the ALS TOR rule includes 2 additional criteria. We extracted OHCA patients meeting all criteria for each TOR rule, and calculated the specificity and positive predictive value (PPV) of each TOR rule for identifying OHCA patients who did not have neurologically favorable one-month survival.

RESULTS

During the study-period, 151,152 cases were available to evaluate the BLS TOR rule, and 137,986 cases to evaluate the ALS TOR rule. Of 113,140 patients that satisfied all three criteria for the BLS TOR rule, 193 (0.2%) had a neurologically favorable one-month survival. The specificity of BLS TOR rule was 0.968 (95% CI: 0.963-0.972), and the PPV was 0.998 (95% CI: 0.998-0.999) for predicting lack of neurologically favorable one-month survival. Of 41,030 patients that satisfied all five criteria for the ALS TOR rule, just 37 (0.1%) had a neurologically favorable one-month survival. The specificity of ALS TOR rule was 0.981 (95% CI: 0.973-0.986), and the PPV was 0.999 (95% CI: 0.998-0.999) for predicting lack of neurologically favorable one-month survival.

CONCLUSIONS

The prehospital BLS and ALS TOR rules performed well in Japan with high specificity and PPV for predicting lack of neurologically favorable one-month survival in Japan. However, the specificity and PPV were not 1000 and we have to develop more specific TOR rules.

"Putting it all together" to improve resuscitation quality

Solutions to improve care provided during cardiac arrest resuscitation attempts must be multifaceted and targeted to the diverse number of care providers to be successful. In this article, new approaches to improving cardiac arrest resuscitation performance are reviewed. The focus is on a continuous quality improvement paradigm highlighting improving training methods before actual cardiac arrest events, monitoring quality during resuscitation attempts, and using quantitative debriefing programs after events to educate frontline care providers.

Impact of resuscitation system errors on survival from in-hospital cardiac arrest

BACKGROUND

An estimated 350,000-750,000 adult, in-hospital cardiac arrest (IHCA) events occur annually in the United States. The impact of resuscitation system errors on survival during IHCA resuscitation has not been evaluated. The purpose of this paper was to evaluate the impact of resuscitation system errors on survival to hospital discharge after IHCA.

METHODS AND RESULTS

We evaluated subjective and objective errors in 118,387 consecutive, adult, index IHCA cases entered into the Get with the Guidelines National Registry of Cardiopulmonary Resuscitation database from January 1, 2000 through August 26, 2008. Cox regression analysis was used to determine the relationship between reported resuscitation system errors and other important clinical variables and the hazard ratio for death prior to hospital discharge. Of the 108,636 patients whose initial IHCA rhythm was recorded, resuscitation system errors were committed in 9,894/24,467 (40.4%) of those with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) and in 22,599/84,169 (26.8%) of those with non-VF/pVT. The most frequent system errors related to delay in medication administration (>5 min time from event recognition to first dose of a vasoconstrictor), defibrillation, airway management, and chest compression performance errors. The presence of documented resuscitation system errors on an IHCA event was associated with decreased rates of return of spontaneous circulation, survival to 24h, and survival to hospital discharge. The relative risk of death prior to hospital discharge based on hazard ratio analysis was 9.9% (95% CI 7.8, 12.0) more likely for patients whose initial documented rhythm was non-VF/pVT when resuscitation system errors were reported compared to when no errors were reported. It was 34.2% (95% CI 29.5, 39.1) more likely for those with VF/pVT.

CONCLUSIONS

The presence of resuscitation system errors that are evident from review of the resuscitation record is associated with decreased survival from IHCA in adults. Hospitals should target the training of first responders and code team personnel to emphasize the importance of early defibrillation, early use of vasoconstrictor medication, and compliance with ACLS protocols.