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Zali M, Rahmani A, Hassankhani H, Namdar-Areshtanab H, Gilani N, Azadi A, Ghafourifard M. Critical care nurses' experiences of caring challenges during post-resuscitation period: a qualitative content analysis. BMC Nurs 2024; 23:150. [PMID: 38433187 PMCID: PMC10910715 DOI: 10.1186/s12912-024-01814-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 02/20/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Patients in the post-resuscitation period experience critical conditions and require high-quality care. Identifying the challenges that critical care nurses encounter when caring for resuscitated patients is essential for improving the quality of their care. AIM This study aimed to identify the challenges encountered by critical care nurses in providing care during the post-resuscitation period. METHODS A qualitative study was conducted using semi-structured interviews. Sixteen nurses working in the intensive care units of three teaching hospitals were selected through purposive sampling. The Data collected were analyzed using qualitative content analysis. RESULTS Participants experienced individual, interpersonal, and organizational challenges when providing post-resuscitation care. The most significant challenges include inadequate clinical knowledge and experience, poor management and communication skills, lack of support from nurse managers, role ambiguity, risk of violence, and inappropriate attitudes of physicians towards nurses' roles. Additionally, nurses expressed a negative attitude towards resuscitated patients. CONCLUSION Critical care nurses face several challenges in providing care for resuscitated patients. To enhance the quality of post-resuscitation care, address the challenges effectively and improve long-time survival it is crucial to implement interventions such as In-service education, post-resuscitation briefing, promotion of interprofessional collaboration among healthcare teams, providing sufficient human resources, clarifying nurses' roles in the post-resuscitation period and increasing support from nursing managers.
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Affiliation(s)
- Mahnaz Zali
- Nursing faculty, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Azad Rahmani
- Nursing faculty, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Hadi Hassankhani
- Nursing faculty, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Neda Gilani
- Health faculty, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Arman Azadi
- Nursing faculty, Ilam University of Medical Sciences, Ilam, Iran
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Kleinman K, Hairston T, Smith B, Billings E, Tackett S, Chopra E, Risko N, Swedien D, Schreurs BA, Dean JL, Scott B, Canares T, Jeffers JM. Pediatric Chest Compression Improvement Via Augmented Reality Cardiopulmonary Resuscitation Feedback in Community General Emergency Departments: A Mixed-Methods Simulation-Based Pilot Study. J Emerg Med 2023; 64:696-708. [PMID: 37438023 PMCID: PMC10360435 DOI: 10.1016/j.jemermed.2023.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/19/2023] [Accepted: 03/11/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Yearly, more than 20,000 children experience a cardiac arrest. High-quality pediatric cardiopulmonary resuscitation (CPR) is generally challenging for community hospital teams, where pediatric cardiac arrest is infrequent. Current feedback systems are insufficient. Therefore, we developed an augmented reality (AR) CPR feedback system for use in many settings. OBJECTIVE We aimed to evaluate whether AR-CPR improves chest compression (CC) performance in non-pediatric-specialized community emergency departments (EDs). METHODS We performed an unblinded, randomized, crossover simulation-based study. A convenience sample of community ED nonpediatric nurses and technicians were included. Each participant performed three 2-min cycles of CC during a simulated pediatric cardiac arrest. Participants were randomized to use AR-CPR in one of three CC cycles. Afterward, participants participated in a qualitative interview to inquire about their experience with AR-CPR. RESULTS Of 36 participants, 18 were randomized to AR-CPR in cycle 2 (group A) and 18 were randomized to AR-CPR in cycle 3 (group B). When using AR-CPR, 87-90% (SD 12-13%) of all CCs were in goal range, analyzed as 1-min intervals, compared with 18-21% (SD 30-33%) without feedback (p < 0.001). Analysis of qualitative themes revealed that AR-CPR may be usable without a device orientation, be effective at cognitive offloading, and reduce anxiety around and enhance confidence in the CC delivered. CONCLUSIONS The novel CPR feedback system, AR-CPR, significantly changed the CC performance in community hospital non-pediatric-specialized general EDs from 18-21% to 87-90% of CC epochs at goal. This study offers preliminary evidence suggesting AR-CPR improves CC quality in community hospital settings.
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Affiliation(s)
- Keith Kleinman
- Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland.
| | - Tai Hairston
- The Harriet Lane Pediatric Residency Program, The Johns Hopkins University, Baltimore, Maryland
| | - Brittany Smith
- Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland
| | - Emma Billings
- Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland
| | - Sean Tackett
- Biostatistics, Epidemiology, and Data Management Core, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Eisha Chopra
- Department of Emergency Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Nicholas Risko
- Department of Emergency Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Daniel Swedien
- Department of Emergency Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Blake A Schreurs
- The Johns Hopkins University Applied Physics Laboratory, LLC, The Johns Hopkins University, Laurel, Maryland
| | - James L Dean
- The Johns Hopkins University Applied Physics Laboratory, LLC, The Johns Hopkins University, Laurel, Maryland
| | - Brandon Scott
- The Johns Hopkins University Applied Physics Laboratory, LLC, The Johns Hopkins University, Laurel, Maryland
| | - Therese Canares
- Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland
| | - Justin M Jeffers
- Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland
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Feasibility of accelerated code team activation with code button triggered smartphone notification. Resuscitation 2023; 187:109752. [PMID: 36842677 DOI: 10.1016/j.resuscitation.2023.109752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/30/2023] [Accepted: 02/20/2023] [Indexed: 02/28/2023]
Abstract
INTRODUCTION Studies support rapid interventions to improve outcomes in patients with in-hospital cardiac arrest. We sought to decrease the time to code team activation and improve dissemination of patient-specific data to facilitate targeted treatments. METHODS We mapped code blue buttons behind each bed to patients through the electronic medical record. Pushing the button sent patient-specific data (admitting diagnosis, presence of difficult airway, and recent laboratory values) through a secure messaging system to the responding teams' smartphones. The code button also activated a hospital-wide alert through the operator. We piloted the system on seven medicine inpatient units from November 2019 through May 2022. We compared the time from code blue button press to smartphone message receipt vs traditional operator-sent overhead page. RESULTS The code button was the primary mode of code team activation for 12/35 (34.3%) cardiac arrest events. The code team received smartphone notifications a median of 78 s (IQR = 47-127 s) before overhead page. The median time to adrenaline administration for codes activated with the code button was not significantly different (240 s (IQR 142-300 s for code button) vs 148 s (IQR = 34-367 s) for overhead page, p = 0.89). Survival to discharge was 3/12 (25.0%) for codes activated with the code button vs 4/23 (17.4%) when activated by calling the operator (p = 0.67). CONCLUSION Implementation of a smartphone-based code button notification system reduced time to code team activation by 78 s. Larger cohorts are necessary to assess effects on patient outcomes.
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Toft LE, Bottinor W, Cobourn A, Blount C, Tripathi A, Mehta I, Koch J. A simulation-enhanced, spaced learning, interprofessional “code blue” curriculum improves ACLS algorithm adherence and trainee resuscitation skill confidence. J Interprof Care 2022; 37:623-628. [DOI: 10.1080/13561820.2022.2140130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Lorrel E.B. Toft
- University of Nevada Reno School of Medicine, Cardiology, 89557, Reno, NV USA
| | - Wendy Bottinor
- Division of Cardiology, Virginia Commonwealth University Medical College of Virginia, Richmond, VA USA
| | - Andrew Cobourn
- University of Nevada Reno School of Medicine, Cardiology, 89557, Reno, NV USA
| | - Courtland Blount
- Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN USA
| | - Avnish Tripathi
- Division of Cardiology, University of Kentucky College of Medicine, Bowling Green, KY USA
| | - Ishan Mehta
- Division of Pulmonology, Emory University School of Medicine, Atlanta, GA USA
| | - Jennifer Koch
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY USA
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Li Y, Lighthall GK. Variations in Code Team Composition During Different Times of Day and Week and by Level of Hospital Complexity. Jt Comm J Qual Patient Saf 2022; 48:564-571. [PMID: 36155176 DOI: 10.1016/j.jcjq.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Previous data demonstrated lower survival rates of in-hospital cardiac arrests during nights and weekends compared to weekday daytime. This study aimed to evaluate variations of personnel attending to codes based on day/night/weekend conditions within the US Veterans Affairs (VA) system, as well as variations of personnel responsible for intubations during codes. METHODS Hospital leaders were surveyed regarding code team membership, leadership, and intubations during four time periods (weekday daytime, weekday nighttime, weekend daytime, and weekend nighttime). RESULTS Surveys were completed for 93 of 123 eligible VA hospitals (response rate of 75.6%). Code teams were significantly smaller during "off-hours." Membership in code teams during regular vs. off-hours was significantly greater for ICU physicians (44.1% vs. 7.5%-15.0%, p < 0.001), anesthesiologists (34.4% vs. 12.9%, p < 0.001), and pharmacists (46.2% vs. 23.7%-26.9%, p < 0.01). Significant differences were found for codes led by ICU attendings (20.4% vs. 5.4%-7.5%, p < 0.05) and intubations performed by ICU attendings (21.5% vs. 6.5%-10.8%, p < 0.05). ICU-based physicians were team leaders more often in high-complexity hospitals (19.7%-50.0% vs. 0%-14.8%), while hospitalists led the majority in the low-complexity hospitals (28.8%-39.4% vs. 63.0%-70.4%). ICU physicians had significantly less involvement in code intubations in low-complexity hospitals (6.1%-22.7% vs. 3.7%-18.5%), while respiratory therapists took on most of this responsibility in low-complexity hospitals and particularly at night. CONCLUSION This study found significant differences in code team composition, leadership, and intubation responsibilities between regular and off-hours. Low-complexity hospitals, which are generally rural, had team compositions and responsibilities that were visibly different from higher-complexity hospitals.
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Clemente Vivancos Á, León Castelao E, Castellanos Ortega Á, Bodi Saera M, Gordo Vidal F, Martin Delgado MC, Jorge-Soto C, Fernandez Mendez F, Igeño Cano JC, Trenado Alvarez J, Caballero Lopez J, Parraga Ramirez MJ. National Survey: How Do We Approach the Patient at Risk of Clinical Deterioration outside the ICU in the Spanish Context? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12627. [PMID: 36231926 PMCID: PMC9565925 DOI: 10.3390/ijerph191912627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Anticipating and avoiding preventable intrahospital cardiac arrest and clinical deterioration are important priorities for international healthcare systems and institutions. One of the internationally followed strategies to improve this matter is the introduction of the Rapid Response Systems (RRS). Although there is vast evidence from the international community, the evidence reported in a Spanish context is scarce. METHODS A nationwide cross-sectional research consisting of a voluntary 31-question online survey was performed. The Spanish Society of Intensive, Critical and Coronary Care Medicine (SEMICYUC) supported the research. RESULTS We received 62 fully completed surveys distributed within 13 of the 17 regions and two autonomous cities of Spain. Thirty-two of the participants had an established Rapid Response Team (RRT). Common frequency on measuring vital signs was at least once per shift but other frequencies were contemplated (48.4%), usually based on professional criteria (69.4%), as only 12 (19.4%) centers used Early Warning Scores (EWS) or automated alarms on abnormal parameters. In the sample, doctors, nurses (55%), and other healthcare professionals (39%) could activate the RRT via telephone, but only 11.3% of the sample enacted this at early signs of deterioration. The responders on the RRT are the Intensive Care Unit (ICU), doctors, and nurses, who are available 24/7 most of the time. Concerning the education and training of general ward staff and RRT members, this varies from basic to advanced and specific-specialized level, simulating a growing educational methodology among participants. A great number of participants have emergency resuscitation equipment (drugs, airway adjuncts, and defibrillators) in their general wards. In terms of quality improvement, only half of the sample registered RRT activity indicators. In terms of the use of communication and teamwork techniques, the most used is clinical debriefing in 29 centers. CONCLUSIONS In terms of the concept of RRS, we found in our context that we are in the early stages of the establishment process, as it is not yet a generalized concept in most of our hospitals. The centers that have it are in still in the process of maturing the system and adapting themselves to our context.
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Affiliation(s)
- Álvaro Clemente Vivancos
- Health Sciences Doctoral Program, Universidad Católica de Murcia (UCAM), 30107 Murcia, Spain
- Advanced Nursing Practice, Hospital del Mar, 08003 Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
| | - Esther León Castelao
- Simulation Laboratory, School of Medicine and Health Sciences, 08036 Barcelona, Spain
- Clinical Simulation Lab, University of Barcelona, 08036 Barcelona, Spain
| | - Álvaro Castellanos Ortega
- Intensive Care Unit Medical Director, University Hospital La Fe, 46026 Valencia, Spain
- Associate Lecturer, University of Valencia, 46010 Valencia, Spain
| | - Maria Bodi Saera
- Intensive Care Unit, University Hospital Joan XIII, 43005 Tarragona, Spain
- Pere I Virgili Health Research Institute, Rovira I Virgili University, 43003 Tarragona, Spain
- Center for Biomedical Research in Respiratory Diseases Network (CIEBERES), Carlos III Health Institute, 28029 Madrid, Spain
| | - Federico Gordo Vidal
- Intensive Care Unit, University Hospital of Henares, 28822 Madrid, Spain
- Critical Pathology Research Group, Francisco de Vitoria University, 28223 Madrid, Spain
| | - Maria Cruz Martin Delgado
- Intensive Care Unit, Hospital 12th of October, 28041 Madrid, Spain
- Facultad de Medicina, Francisco de Vitoria University, 28223 Madrid, Spain
| | - Cristina Jorge-Soto
- CLINURSID Research Group, Psychiatry, Radiology, Public Health, Nursing and Medicine Department, Universidad de Santiago de Compostela, 15705 Galicia, Spain
- Simulation and Intensive Care Unit of Santiago (SICRUS) Research Group, Health Research Institute of Santiago, University Hospital of Santiago de Compostela-CHUS, 15705 Santiago de Compostela, Spain
- Faculty of Nursing, Universidade de Santiago de Compostela, 15705 Santiago de Compostela, Spain
| | - Felipe Fernandez Mendez
- School of Nursing, Universidade de Vigo, 36310 Pontevedra, Spain
- REMOSS Research Group, Universidade de Vigo, 36310 Pontevedra, Spain
| | | | - Josep Trenado Alvarez
- Intensive Care and High Dependency Unit, Mutua Terrassa Hospital, 08221 Terrasa, Spain
- Department of Medicine, University of Barcelona, 08036 Barcelona, Spain
| | - Jesus Caballero Lopez
- Intensive Care Unit, University Hospital Arnau de Vilanova, 25198 Lleida, Spain
- IRBLleida, 25198 Lleida, Spain
| | - Manuel Jose Parraga Ramirez
- Intensive Care Unit, JM Morales Meseguer, 30008 Murcia, Spain
- Simulation and Clinical Skills Director, UCAM, 30107 Murcia, Spain
- Medical Degree Direction Team, UCAM, 30107 Murcia, Spain
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Jeffers JM, Schreurs BA, Dean JL, Scott B, Canares T, Tackett S, Smith B, Billings E, Billioux V, Sampathkumar HD, Kleinman K. Paediatric chest compression performance improves via novel augmented-reality cardiopulmonary resuscitation feedback system: A mixed-methods pilot study in a simulation-based setting. Resusc Plus 2022; 11:100273. [PMID: 35844631 PMCID: PMC9283661 DOI: 10.1016/j.resplu.2022.100273] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/17/2022] [Accepted: 06/27/2022] [Indexed: 12/21/2022] Open
Abstract
Aim More than 20,000 children experience a cardiac arrest event each year in the United States. Most children do not survive. High-quality cardiopulmonary resuscitation (CPR) has been associated with improved outcomes yet adherence to guidelines is poor. We developed and tested an augmented reality head mounted display chest compression (CC) feedback system (AR-CPR) designed to provide real-time CC feedback and guidance. Methods We conducted an unblinded randomized crossover simulation-based study to determine whether AR-CPR changes a user's CC performance. A convenience sample of healthcare providers who perform CC on children were included. Subjects performed three two-minute cycles of CC during a simulated 18-minute paediatric cardiac arrest. Subjects were randomized to utilize AR-CPR in the second or third CC cycle. After, subjects participated in a qualitative portion to inquire about their experience with AR-CPR and offer criticisms and suggestions for future development. Results There were 34 subjects recruited. Sixteen subjects were randomly assigned to have AR-CPR in cycle two (Group A) and 18 subjects were randomized to have AR-CPR in cycle three (Group B). There were no differences between groups CC performance in cycle one (baseline). In cycle two, subjects in Group A had 73% (SD 18%) perfect CC epochs compared to 17% (SD 26%) in Group B (p < 0.001). Overall, subjects enjoyed using AR-CPR and felt it improved their CC performance. Conclusion This novel AR-CPR feedback system showed significant CC performance change closer to CC guidelines. Numerous hardware, software, and user interface improvements were made during this pilot study.
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Affiliation(s)
- Justin M. Jeffers
- Department of Paediatrics, The Johns Hopkins University, Bloomberg Children’s Center, 1800 Orleans St., Baltimore, MD 21287, United States,Corresponding author at: Bloomberg Children’s Center, 1800 Orleans St, Suite G-1509, United States.
| | - Blake A. Schreurs
- The Johns Hopkins University Applied Physics Laboratory, LLC, The Johns Hopkins University, 11100 Johns Hopkins Rd, Laurel, MD 20723, United States
| | - James L. Dean
- The Johns Hopkins University Applied Physics Laboratory, LLC, The Johns Hopkins University, 11100 Johns Hopkins Rd, Laurel, MD 20723, United States
| | - Brandon Scott
- The Johns Hopkins University Applied Physics Laboratory, LLC, The Johns Hopkins University, 11100 Johns Hopkins Rd, Laurel, MD 20723, United States
| | - Therese Canares
- Department of Paediatrics, The Johns Hopkins University, Bloomberg Children’s Center, 1800 Orleans St., Baltimore, MD 21287, United States
| | - Sean Tackett
- Biostatistics, Epidemiology, and Data Management Core, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, United States
| | - Brittany Smith
- Department of Paediatrics, The Johns Hopkins University, Bloomberg Children’s Center, 1800 Orleans St., Baltimore, MD 21287, United States
| | - Emma Billings
- Department of Paediatrics, The Johns Hopkins University, Bloomberg Children’s Center, 1800 Orleans St., Baltimore, MD 21287, United States
| | - Veena Billioux
- Department of Paediatrics, The Johns Hopkins University, Bloomberg Children’s Center, 1800 Orleans St., Baltimore, MD 21287, United States
| | - Harshini D. Sampathkumar
- Department of International Health, Johns Hopkins University School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States
| | - Keith Kleinman
- Department of Paediatrics, The Johns Hopkins University, Bloomberg Children’s Center, 1800 Orleans St., Baltimore, MD 21287, United States
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Bailleul C, Puymirat E, Aegerter P, Guidet B, Guerot E, Augy JL, Brechot N, Diehl JL, Fagon JY, Hermann B, Novara A, Ortuno S, Younan R, Danchin N, Cariou A, Aissaoui N. In-hospital cardiac arrests admitted alive in intensive care units: Insights from the CubRéa database. J Crit Care 2022; 69:154003. [DOI: 10.1016/j.jcrc.2022.154003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 01/21/2022] [Accepted: 01/30/2022] [Indexed: 11/26/2022]
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Chan JL, Nallamothu BK, Tang Y, Roberts JS, Kennedy M, Trumpower B, Chan PS. Resuscitation practices in hospitals caring for children: Insights from get with the guidelines-resuscitation. Resusc Plus 2022; 9:100199. [PMID: 35535342 PMCID: PMC9076952 DOI: 10.1016/j.resplu.2021.100199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/26/2021] [Accepted: 12/26/2021] [Indexed: 11/25/2022] Open
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Picard C, Drew R, Norris CM, O’Dochartaigh D, Burnett C, Keddie C, Douma MJ. Cardiac Arrest Quality Improvement: A Single-Center Evaluation of Resuscitations Using Defibrillator, Feedback Device, and Survey Data. J Emerg Nurs 2022; 48:224-232.e8. [DOI: 10.1016/j.jen.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/26/2021] [Accepted: 11/16/2021] [Indexed: 10/18/2022]
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Shah R, Streat DA, Auerbach M, Shabanova V, Langhan ML. Improving Capnography Use for Critically Ill Emergency Patients: An Implementation Study. J Patient Saf 2022; 18:e26-e32. [PMID: 32175968 PMCID: PMC8719501 DOI: 10.1097/pts.0000000000000683] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Capnography has established benefit during intubation and cardiopulmonary resuscitation (CPR). Implementation within emergency departments (EDs) has lagged. We sought to address barriers to improve documented capnography use for patients requiring intubation or CPR. METHODS A controlled before- and after-implementation study was performed in 2 urban EDs. The control site had an existing policy for capnography use. Interventions for the experimental site included a 5-minute informational video, placement of capnography monitors with a shortened warm-up period in all resuscitation rooms, laminated reminder cards, and feedback during staff meetings. Staff members were surveyed about knowledge before and after the intervention. Records were reviewed for documented capnography use for 3 months before and 6 months after the intervention. Change in documented use at the experimental site was compared with the control site. RESULTS At the experimental site, 118 providers participated and 190 records were reviewed; 544 records were reviewed from the control site. There was a significant increase in the proportion of documented capnography use at the experimental site (8% versus 19%, P = 0.04) compared with the control site (64% versus 71%, P = 0.10). However, there was no significant trend over time at the experimental site after the intervention (P = 0.86). Despite high baseline knowledge about capnography, providers had improvements in survey responses regarding indications for intubation and CPR, normal values, and minimum effective values during CPR. CONCLUSIONS Documented capnography use increased with simple interventions but with no positive trend. Additional work is needed to improve use, including further evaluation of capnography's implementation in the ED.
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Affiliation(s)
- Rahul Shah
- From the Department of Pediatrics, Yale University School of Medicine
| | | | - Marc Auerbach
- Section of Pediatric Emergency Medicine, Department of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Melissa L. Langhan
- Section of Pediatric Emergency Medicine, Department of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
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12
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Pfeiffer S, Lauridsen KG, Wenger J, Hunt EA, Haskell S, Atkins DL, Duval-Arnould JM, Knight LJ, Cheng A, Gilfoyle E, Su F, Balikai S, Skellett S, Hui MY, Niles DE, Roberts JS, Nadkarni VM, Tegtmeyer K, Dewan M. Code Team Structure and Training in the Pediatric Resuscitation Quality International Collaborative. Pediatr Emerg Care 2021; 37:e431-e435. [PMID: 31045955 PMCID: PMC8809371 DOI: 10.1097/pec.0000000000001748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Code team structure and training for pediatric in-hospital cardiac arrest are variable. There are no data on the optimal structure of a resuscitation team. The objective of this study is to characterize the structure and training of pediatric code teams in sites participating in the Pediatric Resuscitation Quality Collaborative. METHODS From May to July 2017, an anonymous voluntary survey was distributed to 18 sites in the international Pediatric Resuscitation Quality Collaborative. The survey content was developed by the study investigators and iteratively adapted by consensus. Descriptive statistics were calculated. RESULTS All sites have a designated code team and hospital-wide code team activation system. Code team composition varies greatly across sites, with teams consisting of 3 to 17 members. Preassigned roles for code team members before the event occur at 78% of sites. A step stool and backboard are used during resuscitations in 89% of surveyed sites. Cardiopulmonary resuscitation (CPR) feedback is used by 72% of the sites. Of those sites that use CPR feedback, all use an audiovisual feedback device incorporated into the defibrillator and 54% use a CPR coach. Multidisciplinary and simulation-based code team training is conducted by 67% of institutions. CONCLUSIONS Code team structure, equipment, and training vary widely in a survey of international children's hospitals. The variations in team composition, role assignments, equipment, and training described in this article will be used to facilitate future studies regarding the impact of structure and training of code teams on team performance and patient outcomes.
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Affiliation(s)
- Stephen Pfeiffer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Kasper Glerup Lauridsen
- Department of Internal Medicine, Randers Regional Hospital
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
| | | | - Elizabeth A. Hunt
- Department of Anesthesiology and Critical Care Medicine, Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sarah Haskell
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Dianne L. Atkins
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Jordan M. Duval-Arnould
- Department of Anesthesiology and Critical Care Medicine, Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lynda J. Knight
- Revive Initiative for Resuscitation Excellence, Stanford Children’s Health, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA
| | - Adam Cheng
- Departments of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Departments of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Elaine Gilfoyle
- Departments of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Departments of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Felice Su
- Revive Initiative for Resuscitation Excellence, Stanford Children’s Health, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA
| | - Shilpa Balikai
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Sophie Skellett
- Department of Paediatric Intensive Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Mok Yee Hui
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
| | - Dana E. Niles
- The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Pediatric Resuscitation Quality Collaborative Investigators
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Internal Medicine, Randers Regional Hospital
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
- Seattle Children’s Hospital, Seattle, WA
- Department of Anesthesiology and Critical Care Medicine, Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, MD
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
- Revive Initiative for Resuscitation Excellence, Stanford Children’s Health, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA
- Departments of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Departments of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Paediatric Intensive Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
- The Children’s Hospital of Philadelphia, Philadelphia, PA
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13
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Mentzelopoulos SD, Couper K, Van de Voorde P, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. [Ethics of resuscitation and end of life decisions]. Notf Rett Med 2021; 24:720-749. [PMID: 34093076 PMCID: PMC8170633 DOI: 10.1007/s10049-021-00888-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- Evaggelismos Allgemeines Krankenhaus, Abteilung für Intensivmedizin, Medizinische Fakultät der Nationalen und Kapodistrischen Universität Athen, 45–47 Ipsilandou Street, 10675 Athen, Griechenland
| | - Keith Couper
- Universitätskliniken Birmingham NHS Foundation Trust, UK Critical Care Unit, Birmingham, Großbritannien
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | - Patrick Van de Voorde
- Universitätsklinikum und Universität Gent, Gent, Belgien
- staatliches Gesundheitsministerium, Brüssel, Belgien
| | - Patrick Druwé
- Abteilung für Intensivmedizin, Universitätsklinikum Gent, Gent, Belgien
| | - Marieke Blom
- Medizinisches Zentrum der Universität Amsterdam, Amsterdam, Niederlande
| | - Gavin D. Perkins
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | | | - Jana Djakow
- Intensivstation für Kinder, NH Hospital, Hořovice, Tschechien
- Abteilung für Kinderanästhesiologie und Intensivmedizin, Universitätsklinikum und Medizinische Fakultät der Masaryk-Universität, Brno, Tschechien
| | - Violetta Raffay
- School of Medicine, Europäische Universität Zypern, Nikosia, Zypern
- Serbischer Wiederbelebungsrat, Novi Sad, Serbien
| | - Gisela Lilja
- Universitätsklinikum Skane, Abteilung für klinische Wissenschaften Lund, Neurologie, Universität Lund, Lund, Schweden
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Robbins AJ, Ingraham NE, Sheka AC, Pendleton KM, Morris R, Rix A, Vakayil V, Chipman JG, Charles A, Tignanelli CJ. Discordant Cardiopulmonary Resuscitation and Code Status at Death. J Pain Symptom Manage 2021; 61:770-780.e1. [PMID: 32949762 PMCID: PMC8052631 DOI: 10.1016/j.jpainsymman.2020.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT One fundamental way to honor patient autonomy is to establish and enact their wishes for end-of-life care. Limited research exists regarding adherence with code status. OBJECTIVES This study aimed to characterize cardiopulmonary resuscitation (CPR) attempts discordant with documented code status at the time of death in the U.S. and to elucidate potential contributing factors. METHODS The Cerner Acute Physiology and Chronic Health Evaluation (APACHE) outcomes database, which includes 237 U.S. hospitals that collect manually abstracted data from all critical care patients, was queried for adults admitted to intensive care units with a documented code status at the time of death from January 2008 to December 2016. The primary outcome was discordant CPR at death. Multivariable logistic regression models were used to identify patient-level and hospital-level associated factors after adjustment for age, hospital, and illness severity (APACHE III score). RESULTS A total of 21,537 patients from 56 hospitals were included. Of patients with a do-not-resuscitate code status, 149 (0.8%) received CPR at death, and associated factors included black race, higher APACHE III score, or treatment in small or nonteaching hospitals. Of patients with a full code status, 203 (9.0%) did not receive CPR at death, and associated factors included higher APACHE III score, primary neurologic or trauma diagnosis, or admission in a more recent year. CONCLUSION At the time of death, 1.6% of patients received or did not undergo CPR in a manner discordant with their documented code statuses. Race and institutional factors were associated with discordant resuscitation, and addressing these disparities may promote concordant end-of-life care in all patients.
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Affiliation(s)
- Alexandria J Robbins
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA.
| | - Nicholas E Ingraham
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Adam C Sheka
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Kathryn M Pendleton
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Rachel Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Alexander Rix
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Victor Vakayil
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jeffrey G Chipman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA; Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA; School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA; Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA; Institute for Health Informatics, University of Minnesota Academic Health Center, Minneapolis, Minnesota, USA
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15
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Mentzelopoulos SD, Couper K, Voorde PVD, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions. Resuscitation 2021; 161:408-432. [PMID: 33773832 DOI: 10.1016/j.resuscitation.2021.02.017] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
| | - Keith Couper
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Patrick Van de Voorde
- University Hospital and University Ghent, Belgium; Federal Department Health, Belgium
| | - Patrick Druwé
- Ghent University Hospital, Department of Intensive Care Medicine, Ghent, Belgium
| | - Marieke Blom
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gavin D Perkins
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Violetta Raffay
- European University Cyprus, School of Medicine, Nicosia, Cyprus; Serbian Resuscitation Council, Novi Sad, Serbia
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
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Abstract
Objective The aim of this systematic review was to synthesize the evidence on the impact of rapid response teams (RRTs) on failure to rescue events. Methods Systematic searches were conducted using CINAHL, MEDLINE, PsychINFO, and Cochrane, for articles published from 2008 to 2018. English-language, peer-reviewed articles reporting the impact of RRTs on failure to rescue events, including hospital mortality and in-hospital cardiac arrest events, were included. For selected articles, the authors abstracted information, with the study designed to be compliant with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Results Ten articles were identified for inclusion: 3 meta-analyses, 3 systematic reviews, and 4 single studies. The systematic reviews and meta-analyses were of moderate-to-high quality, limited by the methodological quality of the included individual studies. The single studies were both observational and investigational in design. Patient outcomes included hospital mortality (8 studies), in-hospital cardiac arrests (9 studies), and intensive care unit (ICU) transfer rates (5 studies). There was variation in the composition of RRTs, and 4 studies conducted subanalyses to examine the effect of physician inclusion on patient outcomes. Conclusions There is moderate evidence linking the implementation of RRTs with decreased mortality and non-ICU cardiac arrest rates. Results linking RRT to ICU transfer rates are inconclusive and challenging to interpret. There is some evidence to support the use of physician-led teams, although evaluation of team composition was variable. Lastly, the benefits of RRTs may take a significant period after implementation to be realized, owing to the need for change in safety culture.
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Racial disparities in survival outcomes following pediatric in-hospital cardiac arrest. Resuscitation 2021; 159:117-125. [PMID: 33400929 DOI: 10.1016/j.resuscitation.2020.12.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/13/2020] [Accepted: 12/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Among adults with in-hospital cardiac arrest (IHCA), overall survival is lower in black patients compared to white patients. Data regarding racial differences in survival for pediatric IHCA are unknown. METHODS Using 2000-2017 data from the American Heart Association Get With the Guidelines-Resuscitation® registry, we identified children >24 h and <18 years of age with IHCA due to an initial pulseless rhythm. We used generalized estimation equation to examine the association of black race with survival to hospital discharge, return of spontaneous circulation (ROSC), and favorable neurologic outcome at discharge. RESULTS Overall, 2940 pediatric patients (898 black, 2042 white) at 224 hospitals with IHCA were included. The mean age was 3.0 years, 57% were male and 16% had an initial shockable rhythm. Age, sex, interventions in place at the time of arrest and cardiac arrest characteristics did not differ significantly by race. The overall survival to discharge was 36.9%, return of spontaneous circulation (ROSC) was 73%, and favorable neurologic survival was 20.8%. Although black race was associated with lower rates of ROSC compared to white patients (69.5% in blacks vs. 74.6% in whites; risk-adjusted OR 0.79, 95% CI 0.67-0.94, P = 0.016), black race was not associated with survival to discharge (34.7% in blacks vs. 37.8% in whites; risk-adjusted OR 0.96, 95% CI 0.80-1.15, P = 0.68) or favorable neurologic outcome (18.7% in blacks vs. 21.8% in whites, risk-adjusted OR 0.98, 95% CI 0.80-1.20, p = 0.85). CONCLUSIONS In contrast to adults, we did not find evidence for racial differences in survival outcomes following IHCA among children.
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18
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Picard C, Yang BG, Norris C, McIntosh S, Douma MJ. Cardiopulmonary Resuscitation Feedback: A Comparison of Device-Measured and Self-Assessed Chest Compression Quality. J Emerg Nurs 2020; 47:333-341.e1. [PMID: 33308832 DOI: 10.1016/j.jen.2020.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/10/2020] [Accepted: 10/12/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND High-quality cardiopulmonary resuscitation is the foundation of cardiac arrest care. Guidelines specify chest compression depth, recoil, and rate, but providers often fail to achieve these targets. Furthermore, providers are largely unable assess the quality of their own or other peoples' chest compressions. Chest compression feedback devices can improve chest compression quality; their use is endorsed internationally, but they remain largely absent in clinical care. This article analyzes preclinical data collected during a quality improvement project. It describes provider demographics and perceptions about their chest compression quality and correlates them to measured chest compression quality, compares clinician perception of chest compressions to objective measures, and describes the effect of feedback on compression quality. METHODS Clinicians were recruited from 2 metropolitan emergency departments. A questionnaire was used to assess participants' levels of training and experience. A before-and-after assessment of chest compression quality was performed using a Laerdal CPRmeter 2 and a CPR mannequin. Pretest measures of chest compression quality were made by covering the device screen thereby blinding providers to feedback; repeat measures were then collected from the same participants but unblinded to feedback. Provider charecteristic were collected by survey. Correlations between blinded chest compression quality and provider charecteristics; the reliability of providers estimated compared to measured quality; and the effects of feedback on chest compression quality were assessed using Pearsons correlations, Cohens κ, and paired t testing. RESULTS 84 participants were assessed. The mean years of certification were 11.74. Ninty-five percent of the providers self-assessed as more experienced than novice and 81% reported performing cardiopulmonary resuscitation at least occasionally. The frequency of performing chest compressions was correlated with self-assessed skill (r = 0.58, P < .001). However, self-assessed skill was only weakly correlated with chest compression quality (r = 0.29, P = .01) and not at all with the frequency of performing chest compressions or years of certification. There was no agreement between self-assessed and device-measured chest compression depth (κ = -0.10, P = 0.11), recoil (κ = -0.14, P = .03), or rate (κ = 0.06, P =.30). The overall quality of compressions improved by 16.9%; the percentage of chest compressions achieving target depth by 3.58%; recoil by 22.82%; and rate by 23.66% with feedback. A total of 97.6% of the staff rated chest compression feedback helpful. CONCLUSIONS Our findings suggest that participants' demographics were not correlated with chest compression quality and that providers cannot reliably assess chest compression quality. The data also demonstrate that with minimal training, feedback can significantly improve chest compression quality.
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Badke CM, Friedman ML, Harris ZL, McCarthy-Kowols M, Tran S. Impact of an untrained CPR Coach in simulated pediatric cardiopulmonary arrest: A pilot study. Resusc Plus 2020; 4:100035. [PMID: 34223312 PMCID: PMC8244490 DOI: 10.1016/j.resplu.2020.100035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/21/2020] [Accepted: 09/25/2020] [Indexed: 11/21/2022] Open
Abstract
Aim To determine if an untrained cardiopulmonary resuscitation (CPR) Coach, with no access to real-time CPR feedback technology, improves CPR quality. Methods This was a prospective randomized pilot study at a tertiary care children's hospital that aimed to integrate an untrained CPR Coach into resuscitation teams during simulated pediatric cardiac arrest. Simulation events were randomized to two arms: control (no CPR Coach) or intervention (CPR Coach). Simulations were run by pediatric intensive care unit (PICU) providers and video recorded. Scenarios focused on full cardiopulmonary arrest; neither team had access to real-time CPR feedback technology. The primary outcome was CPR quality. Secondary outcomes included workload assessments of the team leader and CPR Coach using the NASA Task Load Index and perceptions of CPR quality. Results Thirteen simulations were performed; 5 were randomized to include a CPR Coach. There was a significantly shorter duration to backboard placement in the intervention group (median 20 s [IQR 0–27 s] vs. 52 s [IQR 38–65 s], p = 0.02). There was no self-reported change in the team leader's workload between scenarios using a CPR Coach compared to those without a CPR Coach. There were no significant changes in subjective CPR quality measures. Conclusions In this pilot study, inclusion of an untrained CPR Coach during simulated CPR shortened time to backboard placement but did not improve most metrics of CPR quality or significantly affect team leader workload. More research is needed to better assess the value of a CPR Coach and its potential impact in real-world resuscitation.
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Affiliation(s)
- Colleen M. Badke
- Division of Critical Care Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL 60611, United States
- Corresponding author.
| | - Matthew L. Friedman
- Division of Pediatric Critical Care, Indiana University, 705 Riley Hospital Drive, Rm 4900, Indianapolis, IN 46202, United States
| | - Z. Leah Harris
- Division of Critical Care Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL 60611, United States
| | - Maureen McCarthy-Kowols
- Division of Critical Care Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL 60611, United States
| | - Sifrance Tran
- Division of Pediatric Surgery, Department of Surgery, University of Texas Medical Branch – Galveston, 301 University Blvd., Galveston, TX 77555-0353, United States
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Couper K, Mason AJ, Gould D, Nolan JP, Soar J, Yeung J, Harrison D, Perkins GD. The impact of resuscitation system factors on in-hospital cardiac arrest outcomes across UK hospitals: An observational study. Resuscitation 2020; 151:166-172. [PMID: 32304804 DOI: 10.1016/j.resuscitation.2020.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/10/2020] [Accepted: 04/05/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE OF THE STUDY To explore whether variation in in-hospital cardiac arrest (IHCA) survival can be explained by differences in resuscitation service provision across UK acute hospitals. METHODS We linked information on key clinical practices with patient data of adults who had a cardiac arrest on a general hospital ward or emergency admissions unit in 2016/17. We used multi-level Bayesian models to explore associations between system quality indicators (number of resuscitation officers, audits time to first shock, review unexpected non-survivors, arrest team meets at handover, hot debrief, cold debrief, real-time audio-visual feedback, frequency of mock arrest provision) and adjusted hospital survival. RESULTS We received survey responses from 110 out of 180 eligible hospitals (response rate 61%) relating to 12,285 cardiac arrest cases. Variation across trusts was observed in the number of resuscitation officers (median 0.7 (interquartile range 0.5, 0.9) per 750 clinical staff employed. Key system quality indicators were undertaken infrequently: audit of time to first shock (44.7%), arrest team meeting at handover (28.9%), mock arrests ≥ monthly (22.4%), and use of CPR feedback devices (18.4%). The probability that the system quality indicators had a positive effect on hospital survival ranged from 10% to 89%. However, there was uncertainty in the estimated odds ratios and we cannot exclude the possibility of a clinical benefit. Findings were consistent across secondary outcomes. CONCLUSION In this study, we identified variation in implementation of system quality indicators. Amongst hospitals that responded to our survey, the probability that individual factors increase the odds of hospital survival ranges from 10 to 89%.
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Affiliation(s)
- Keith Couper
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Doug Gould
- Intensive Care National Audit & Research Centre, London, UK
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Royal United Hospital, Royal United Hospitals Bath NHS Trust, Bath, UK
| | - Jasmeet Soar
- Critical Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Harrison
- Intensive Care National Audit & Research Centre, London, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Douthit NT, McBride CM, Townsley EC. Increasing Internal Medicine Resident Confidence in Leading Inpatient Cardiopulmonary Resuscitations and Improving Patient Outcomes. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2020; 7:2382120520923716. [PMID: 32518830 PMCID: PMC7252364 DOI: 10.1177/2382120520923716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Residents do not feel confident or competent in leading inpatient resuscitations. This is a crucial part of training future internists. Our objective was to develop a low-cost intervention to improve resident confidence in leading cardiopulmonary resuscitations and patient outcomes. METHODS A "code-conference" including a lecture on a high-yield topic, a low-fidelity simulation, and review of resident-led resuscitations was created at our institution for the 2017-2018 academic year. Patient outcomes were assessed using objective measures of return of spontaneous circulation (ROSC) and survival to discharge (sDC). Confidence was assessed via survey before and after the intervention, with a focus on beginning postgraduate year 2 (PGY-2) residents. RESULTS In 2017, 8 out of 8 (100%) PGY-2 residents responded, while in 2018, 8 out of 10 (80%) responded. Patient outcomes did not show a statistically significant improvement. There was a trend toward positive outcomes in the resident group alone. Return of spontaneous circulation increased from 63% to 79% (P = .08, total n = 97). Resident confidence was not improved in a statistically significant way, but there was a trend toward improvement and residents agreed it was an important part of their training. DISCUSSION There was no statistically significant improvement in code-blue outcomes; however, there was a positive trend with increased ROSC and stable sDC for resident-led resuscitations, despite hospital-wide decreases in both. Resident confidence also showed a positive trend with no statistical significant changes. It is possible to institute a low-cost high-yield intervention to improved resident confidence in leading code-blue resuscitations. It may also improve patient outcomes; however, further studies are needed to determine if it can improve patient survival outcomes.
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Affiliation(s)
- Nathan T Douthit
- Department of Internal Medicine, Brookwood Baptist Health Medical Education, Birmingham, AL, USA
| | | | - Erin Coleman Townsley
- Internal Medicine Residency, Brookwood Baptist Health Medical Education, Birmingham, AL, USA
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Kim S, Ahn KO, Ro YS, Shin SD. Factors Associated with the Transfer Decision in Resuscitated Patients with Out-of-Hospital Cardiac Arrest Presenting to a Hospital with Limited Targeted Temperature Management Capability in Korea. Ther Hypothermia Temp Manag 2019; 9:224-230. [DOI: 10.1089/ther.2018.0039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sola Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Ki Ok Ahn
- Department of Emergency Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang-si, Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Sang Do Shin
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
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Regional trends in In-hospital Cardiac Arrest following sepsis-related admissions and subsequent mortality. Resuscitation 2019; 143:35-41. [DOI: 10.1016/j.resuscitation.2019.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/19/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
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Predictors of In-Hospital Mortality After Rapid Response Team Calls in a 274 Hospital Nationwide Sample. Crit Care Med 2019; 46:1041-1048. [PMID: 29293147 DOI: 10.1097/ccm.0000000000002926] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Despite wide adoption of rapid response teams across the United States, predictors of in-hospital mortality for patients receiving rapid response team calls are poorly characterized. Identification of patients at high risk of death during hospitalization could improve triage to intensive care units and prompt timely reevaluations of goals of care. We sought to identify predictors of in-hospital mortality in patients who are subjects of rapid response team calls and to develop and validate a predictive model for death after rapid response team call. DESIGN Analysis of data from the national Get with the Guidelines-Medical Emergency Team event registry. SETTING Two-hundred seventy four hospitals participating in Get with the Guidelines-Medical Emergency Team from June 2005 to February 2015. PATIENTS 282,710 hospitalized adults on surgical or medical wards who were subjects of a rapid response team call. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was death during hospitalization; candidate predictors included patient demographic- and event-level characteristics. Patients who died after rapid response team were older (median age 72 vs 66 yr), were more likely to be admitted for noncardiac medical illness (70% vs 58%), and had greater median length of stay prior to rapid response team (81 vs 47 hr) (p < 0.001 for all comparisons). The prediction model had an area under the receiver operating characteristic curve of 0.78 (95% CI, 0.78-0.79), with systolic blood pressure, time since admission, and respiratory rate being the most important variables. CONCLUSIONS Patients who die following rapid response team calls differ significantly from surviving peers. Recognition of these factors could improve postrapid response team triage decisions and prompt timely goals of care discussions.
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Mitchell OJL, Motschwiller CW, Horowitz JM, Friedman OA, Nichol G, Evans LE, Mukherjee V. Rapid Response and Cardiac Arrest Teams: A Descriptive Analysis of 103 American Hospitals. Crit Care Explor 2019; 1:e0031. [PMID: 32166272 PMCID: PMC7063949 DOI: 10.1097/cce.0000000000000031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Despite improvements in the management of in-hospital cardiac arrest over the past decade, in-hospital cardiac arrest continues to be associated with poor prognosis. This has led to the development of rapid response systems, hospital-wide efforts to improve patient outcomes by centering on prompt identification of decompensating patients, expert clinical management, and continuous quality improvement of processes of care. The rapid response system may include cardiac arrest teams, which are centered on identification and treatment of patients with in-hospital cardiac arrest. However, few evidence-based guidelines exist to guide the formation of such teams, and the degree of their variation across the United States has not been well described. DESIGN Descriptive cross-sectional, internet-based survey. SETTING Cohort of preidentified clinicians involved in their hospital's adult rapid response system across the United States. SUBJECTS Clinicians who had been identified by study team members using personal and professional contacts over a 7-month period from June 2018 to December 2018. INTERVENTIONS An 80-item survey was developed by the investigators. It sought information on the afferent (identification and notification of providers) and efferent (response of providers to patient) limbs of the rapid response system, as well as management of patients post in-hospital cardiac arrest. MEASUREMENTS AND MAIN RESULTS One-hundred fourteen surveys were distributed. Of these, 109 (96%) were completed. Six were duplicates and were excluded, leaving a total of 103 surveys from 103 hospitals in 30 states. Seventy-six percent of hospitals were academic, 30% were large hospitals (> 750 inpatient beds), and 58% had large ICUs (> 50 ICU beds). We found wide variation in the structure and function in both the afferent and efferent limbs of the rapid response system. The majority of hospitals had a rapid response team and a cardiac arrest team. Most rapid response teams contained a provider, a critical care nurse, and a respiratory therapist. In hospitals with training programs in internal medicine, anesthesia, emergency medicine, or critical care, 45% of rapid response teams and 75% of cardiac arrest teams were led by trainees, with inconsistent attending presence. Targeted temperature management and coronary catheterization were widely used post in-hospital cardiac arrest, but indications varied considerably. CONCLUSIONS We have demonstrated substantial variation in the structure and function of rapid response systems as well as in management of patients during and after in-hospital cardiac arrest.
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Affiliation(s)
| | | | | | | | - Graham Nichol
- Department of Medicine, University of Washington, Seattle, WA
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Laura E. Evans
- Medical Director of Critical Care, Bellevue Hospital, New York School of Medicine, New York, NY
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York School of Medicine, New York, NY
| | - Vikramjit Mukherjee
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York School of Medicine, New York, NY
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Schluep M, van Limpt GJC, Stolker RJ, Hoeks SE, Endeman H. Cardiopulmonary resuscitation practices in the Netherlands: results from a nationwide survey. BMC Health Serv Res 2019; 19:333. [PMID: 31126275 PMCID: PMC6534892 DOI: 10.1186/s12913-019-4166-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 05/17/2019] [Indexed: 01/05/2023] Open
Abstract
Background Survival rates after in-hospital cardiac arrest are low and vary across hospitals. The ERC guidelines state that more research is needed to explore factors that could influence survival. Research into the role of cardiopulmonary resuscitation (CPR) practices is scarce. The goal of this survey is to gain information about CPR practices among hospitals in the Netherlands. Methods A survey was distributed to all Dutch hospital organizations (n = 77). Items investigated were general hospital characteristics, pre-, peri- and post-resuscitation care. Characteristics were stratified by hospital teaching status. Results Out of 77 hospital organizations, 71 (92%) responded to the survey, representing 99 locations. Hospitals were divided into three categories: university hospitals (8%), teaching hospitals (64%) and non-teaching hospitals (28%). Of all locations, 96% used the most recent guidelines for Advanced Life Support and 91% reported the availability of a Rapid Response System. Training frequencies varied from twice a year in 41% and once a year in 53% of hospital locations. The role of CPR team leader and airway manager is most often fulfilled by (resident) anaesthetists in university hospitals (63%), by emergency department professionals in teaching hospitals (43%) and by intensive care professionals in non-teaching hospitals (72%). The role of airway manager is most often attributed to (resident) anaesthetists in university hospitals (100%), and to intensive care professionals in teaching (82%) and non-teaching hospitals (79%). Conclusion The majority of Dutch hospitals follow the ERC guidelines but there are differences in the presence of an ALS certified physician, intensity of training and participation of medical specialties in the fulfilment of roles within the CPR-team. Electronic supplementary material The online version of this article (10.1186/s12913-019-4166-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marc Schluep
- Department of Anaesthesia, Erasmus University Medical Centre, P.O. Box 2040, 3000CA, Rotterdam, the Netherlands.
| | | | - Robert Jan Stolker
- Department of Anaesthesia, Erasmus University Medical Centre, P.O. Box 2040, 3000CA, Rotterdam, the Netherlands
| | - Sanne Elisabeth Hoeks
- Department of Anaesthesia, Erasmus University Medical Centre, P.O. Box 2040, 3000CA, Rotterdam, the Netherlands
| | - Henrik Endeman
- Department of Intensive Care Medicine, Erasmus University Medical Centre, Rotterdam, the Netherlands
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Lee BY, Hong SB. Rapid response systems in Korea. Acute Crit Care 2019; 34:108-116. [PMID: 31723915 PMCID: PMC6786673 DOI: 10.4266/acc.2019.00535] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 05/17/2019] [Accepted: 05/20/2019] [Indexed: 11/30/2022] Open
Abstract
The inpatient treatment process is becoming more and more complicated with advanced treatments, aging of the patient population, and multiple comorbidities. During the process, patients often experience unexpected deterioration, about half of which might be preventable. Early identification of patient deterioration and the proper response are priorities in most healthcare facilities. A rapid response system (RRS) is a safety net to identify antecedents of these adverse events and to respond in a timely manner. The RRS has become an essential part of the medical system worldwide, supported by all major quality improvement organizations. An RRS consists of a trigger system and response team and needs constant assessment and process improvement. Although the effectiveness and cost-benefit of RRS remain controversial, according to previous studies, it may be beneficial by decreasing in-hospital cardiac arrest and mortality. Since the first implementation of RRS in Korea in 2008, it has been developed in over 15 medical centers and continues to expand. Recent accreditation standards and an RRS pilot program by the Korean government will promote the proliferation of RRSs in Korea.
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Affiliation(s)
- Bo Young Lee
- Division of Allergy and Respiratory Diseases, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Mitchell OJL, Motschwiller CW, Horowitz JM, Evans LE, Mukherjee V. Characterising variation in composition and activation criteria of rapid response and cardiac arrest teams: a survey of Medicare participating hospitals in five American states. BMJ Open 2019; 9:e024548. [PMID: 30852537 PMCID: PMC6429839 DOI: 10.1136/bmjopen-2018-024548] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To characterise the variation in composition, leadership, and activation criteria of rapid response and cardiac arrest teams in five north-eastern states of the USA. DESIGN Cross-sectional study consisting of a voluntary 46-question survey of acute care hospitals in north-eastern USA. SETTING Acute care hospitals in New York, New Jersey, Rhode Island, Vermont, and Pennsylvania. PARTICIPANTS Surveys were completed by any member of the rapid response team (RRT) with a working knowledge of team composition and function. Participants were all Medicare-participating acute care hospitals, including teaching and community hospitals as well as hospitals from rural, urban and suburban areas. RESULTS Out of 378 hospitals, contacts were identified for 303, and 107 surveys were completed. All but two hospitals had an RRT, 70% of which changed members daily. The most common activation criteria were clinical concern (95%), single vital sign abnormalities (77%) and early warning score (59%). Eighty one per cent of hospitals had a dedicated cardiac arrest team.RRT composition varied widely, with respiratory therapists, critical care nurses, physicians and nurse managers being the most likely to attend (89%, 78%, 64% and 51%, respectively). Consistent presence of critical care physicians was uncommon and both cardiac arrest teams and teams were frequently led by trainee physicians, often without senior supervision. CONCLUSIONS As the largest study to date in the USA, we have demonstrated wide heterogeneity, rapid team turnover and a lack of senior supervision of RRT and cardiac arrest teams. These factors likely contribute to the mixed results seen in studies of RRTs.
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Affiliation(s)
- Oscar J L Mitchell
- Department of Internal Medicine, New York University School of Medicine, New York City, New York, USA
| | - Caroline W Motschwiller
- Department of Internal Medicine, New York University School of Medicine, New York City, New York, USA
| | - James M Horowitz
- Division of Cardiology, New York University School of Medicine, New York City, New York, USA
| | - Laura E Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York City, New York, USA
| | - Vikramjit Mukherjee
- Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York City, New York, USA
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Li C, Xu J, Han F, Walline J, Zheng L, Fu Y, Zhu H, Chai Y, Yu X. Identification of return of spontaneous circulation during cardiopulmonary resuscitation via pulse oximetry in a porcine animal cardiac arrest model. J Clin Monit Comput 2018; 33:843-851. [PMID: 30498975 DOI: 10.1007/s10877-018-0230-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
Abstract
In this prospective study we investigated whether the pulse oximetry plethysmographic waveform (POP) could be used to identify return of spontaneous circulation (ROSC) during cardio-pulmonary resuscitation (CPR). Tweleve pigs (28 ± 2 kg) were randomly assigned to two groups: Group I (non-arrested with compressions) (n = 6); Group II (arrested with CPR and defibrillation) (n = 6). Hemodynamic parameters and POP were collected and analyzed. POP was analyzed using both a time domain method and a frequency domain method. In Group I, when compressions were carried out on subjects with a spontaneous circulation, a hybrid fluctuation or "envelope" phenomenon appeared in the time domain method and a "double" or "fusion" peak appeared in the frequency domain method. In Group II, after the period of ventricular fibrillation was induced, the POP waveform disappeared. With compressions, POP showed a regular compression wave. After defibrillation, ROSC, and continued compressions, a hybrid fluctuation or "envelope" phenomenon appeared in the time domain method and a "double" or "fusion" peak appeared in the frequency domain method, similar to Group I. Analysis of POP using the time and frequency domain methods could be used to identify ROSC during CPR.
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Affiliation(s)
- Chen Li
- Emergency Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Jun Xu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, China.
| | - Fei Han
- Institute of Life Monitoring, Mindray Corporation, Shenzhen, China
| | - Joseph Walline
- Division of Emergency Medicine, Department of Surgery, Saint Louis University Hospital, Saint Louis, MO, USA
| | - Liangliang Zheng
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, China
| | - Yangyang Fu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, China
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, China
| | - Yanfen Chai
- Emergency Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, China
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Nallamothu BK, Guetterman TC, Harrod M, Kellenberg JE, Lehrich JL, Kronick SL, Krein SL, Iwashyna TJ, Saint S, Chan PS. How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed? A Qualitative Study. Circulation 2018; 138:154-163. [PMID: 29986959 PMCID: PMC6245659 DOI: 10.1161/circulationaha.118.033674] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/12/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND In-hospital cardiac arrest (IHCA) is common, and outcomes vary substantially across US hospitals, but reasons for these differences are largely unknown. We set out to better understand how top-performing hospitals organize their resuscitation teams to achieve high survival rates for IHCA. METHODS We calculated risk-standardized IHCA survival to discharge rates across American Heart Association Get With The Guidelines-Resuscitation registry hospitals between 2012 and 2014. We identified geographically and academically diverse hospitals in the top, middle, and bottom quartiles of survival for IHCA and performed a qualitative study that included site visits with in-depth interviews of clinical and administrative staff at 9 hospitals. With the use of thematic analysis, data were analyzed to identify salient themes of perceived performance by informants. RESULTS Across 9 hospitals, we interviewed 158 individuals from multiple disciplines including physicians (17.1%), nurses (45.6%), other clinical staff (17.1%), and administration (20.3%). We identified 4 broad themes related to resuscitation teams: (1) team design, (2) team composition and roles, (3) communication and leadership during IHCA, and (4) training and education. Resuscitation teams at top-performing hospitals demonstrated the following features: dedicated or designated resuscitation teams; participation of diverse disciplines as team members during IHCA; clear roles and responsibilities of team members; better communication and leadership during IHCA; and in-depth mock codes. CONCLUSIONS Resuscitation teams at hospitals with high IHCA survival differ from non-top-performing hospitals. Our findings suggest core elements of successful resuscitation teams that are associated with better outcomes and form the basis for future work to improve IHCA.
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Affiliation(s)
- Brahmajee K Nallamothu
- Departments of Internal Medicine (B.K.N., J.E.K., J.L.L., S.L. Krein, T.J.I., S.S.)
- University of Michigan Medical School, Ann Arbor. Veterans Affairs Ann Arbor Center for Clinical Management Research, MI (B.K.N., S.L. Krein, T.J.I., S.S.)
| | | | | | - Joan E Kellenberg
- Departments of Internal Medicine (B.K.N., J.E.K., J.L.L., S.L. Krein, T.J.I., S.S.)
| | - Jessica L Lehrich
- Departments of Internal Medicine (B.K.N., J.E.K., J.L.L., S.L. Krein, T.J.I., S.S.)
| | | | - Sarah L Krein
- Departments of Internal Medicine (B.K.N., J.E.K., J.L.L., S.L. Krein, T.J.I., S.S.)
- University of Michigan Medical School, Ann Arbor. Veterans Affairs Ann Arbor Center for Clinical Management Research, MI (B.K.N., S.L. Krein, T.J.I., S.S.)
| | - Theodore J Iwashyna
- Departments of Internal Medicine (B.K.N., J.E.K., J.L.L., S.L. Krein, T.J.I., S.S.)
- University of Michigan Medical School, Ann Arbor. Veterans Affairs Ann Arbor Center for Clinical Management Research, MI (B.K.N., S.L. Krein, T.J.I., S.S.)
| | - Sanjay Saint
- Departments of Internal Medicine (B.K.N., J.E.K., J.L.L., S.L. Krein, T.J.I., S.S.)
- University of Michigan Medical School, Ann Arbor. Veterans Affairs Ann Arbor Center for Clinical Management Research, MI (B.K.N., S.L. Krein, T.J.I., S.S.)
| | - Paul S Chan
- Department of Internal Medicine, Saint Luke's Health System, Kansas City, MO (P.S.C.)
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Lyons PG, Edelson DP, Churpek MM. Rapid response systems. Resuscitation 2018; 128:191-197. [PMID: 29777740 DOI: 10.1016/j.resuscitation.2018.05.013] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/20/2018] [Accepted: 05/09/2018] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Rapid response systems are commonly employed by hospitals to identify and respond to deteriorating patients outside of the intensive care unit. Controversy exists about the benefits of rapid response systems. AIMS We aimed to review the current state of the rapid response literature, including evolving aspects of afferent (risk detection) and efferent (intervention) arms, outcome measurement, process improvement, and implementation. DATA SOURCES Articles written in English and published in PubMed. RESULTS Rapid response systems are heterogeneous, with important differences among afferent and efferent arms. Clinically meaningful outcomes may include unexpected mortality, in-hospital cardiac arrest, length of stay, cost, and processes of care at end of life. Both positive and negative interventional studies have been published, although the two largest randomized trials involving rapid response systems - the Medical Early Response and Intervention Trial (MERIT) and the Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients (EPOCH) trial - did not find a mortality benefit with these systems, albeit with important limitations. Advances in monitoring technologies, risk assessment strategies, and behavioral ergonomics may offer opportunities for improvement. CONCLUSIONS Rapid responses may improve some meaningful outcomes, although these findings remain controversial. These systems may also improve care for patients at the end of life. Rapid response systems are expected to continue evolving with novel developments in monitoring technologies, risk prediction informatics, and work in human factors.
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Affiliation(s)
- Patrick G Lyons
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Dana P Edelson
- Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Matthew M Churpek
- Department of Medicine, University of Chicago, Chicago, IL, United States.
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Chan PS, Krein SL, Tang F, Iwashyna TJ, Harrod M, Kennedy M, Lehrich J, Kronick S, Nallamothu BK. Resuscitation Practices Associated With Survival After In-Hospital Cardiac Arrest: A Nationwide Survey. JAMA Cardiol 2018; 1:189-97. [PMID: 27437890 DOI: 10.1001/jamacardio.2016.0073] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Although survival of patients with in-hospital cardiac arrest varies markedly among hospitals, specific resuscitation practices that distinguish sites with higher cardiac arrest survival rates remain unknown. OBJECTIVE To identify resuscitation practices associated with higher rates of in-hospital cardiac arrest survival. DESIGN, SETTING, AND PARTICIPANTS Nationwide survey of resuscitation practices at hospitals participating in the Get With the Guidelines-Resuscitation registry and with 20 or more adult in-hospital cardiac arrest cases from January 1, 2012, through December 31, 2013. Data analysis was performed from June 10 to December 22, 2015. MAIN OUTCOMES AND MEASURES Risk-standardized survival rates for cardiac arrest were calculated at each hospital and were then used to categorize hospitals into quintiles of performance. The association between resuscitation practices and quintiles of survival was evaluated using hierarchical proportional odds logistic regression models. RESULTS Overall, 150 (78.1%) of 192 eligible hospitals completed the study survey, and 131 facilities with 20 or more adult in-hospital cardiac arrest cases comprised the final study cohort. Risk-standardized survival rates after in-hospital cardiac arrest varied substantially (median, 23.7%; range, 9.2%-37.5%). Several resuscitation practices were associated with survival on bivariate analysis, although only 3 were significant after multivariable adjustment: monitoring for interruptions in chest compressions (adjusted odds ratio [OR] for being in a higher survival quintile category, 2.71; 95% CI, 1.24-5.93; P = .01), reviewing cardiac arrest cases monthly (adjusted OR for being in a higher survival quintile category, 8.55; 95% CI, 1.79-40.00) or quarterly (OR, 6.85; 95% CI, 1.49-31.30; P = .03), and adequate resuscitation training (adjusted OR, 3.23; 95% CI, 1.21-8.33; P = .02). CONCLUSIONS AND RELEVANCE Using survey information from acute care hospitals participating in a national quality improvement registry, we identified 3 resuscitation strategies associated with higher hospital rates of survival for patients with in-hospital cardiac arrest. These strategies can form the foundation for best practices for resuscitation care at hospitals given the high incidence and variation in survival for in-hospital cardiac arrest.
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Affiliation(s)
- Paul S Chan
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri2Department of Medicine, University of Missouri, Kansas City
| | - Sarah L Krein
- The Veterans Affairs Health Services Research and Development Center of Innovation, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan4Department of Internal Medicine, Center for Healthcare Outcomes and Policy, University of Michigan, Ann A
| | - Fengming Tang
- Department of Medicine, University of Missouri, Kansas City
| | - Theodore J Iwashyna
- The Veterans Affairs Health Services Research and Development Center of Innovation, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan4Department of Internal Medicine, Center for Healthcare Outcomes and Policy, University of Michigan, Ann A
| | - Molly Harrod
- The Veterans Affairs Health Services Research and Development Center of Innovation, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Mary Kennedy
- Department of Medicine, University of Missouri, Kansas City
| | - Jessica Lehrich
- Department of Internal Medicine, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Steven Kronick
- The Veterans Affairs Health Services Research and Development Center of Innovation, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan4Department of Internal Medicine, Center for Healthcare Outcomes and Policy, University of Michigan, Ann A
| | - Brahmajee K Nallamothu
- The Veterans Affairs Health Services Research and Development Center of Innovation, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan4Department of Internal Medicine, Center for Healthcare Outcomes and Policy, University of Michigan, Ann A
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Abstract
OBJECTIVE Failure to detect clinical deterioration in the hospital is common and associated with poor patient outcomes and increased healthcare costs. Our objective was to evaluate the feasibility and accuracy of real-time risk stratification using the electronic Cardiac Arrest Risk Triage score, an electronic health record-based early warning score. DESIGN We conducted a prospective black-box validation study. Data were transmitted via HL7 feed in real time to an integration engine and database server wherein the scores were calculated and stored without visualization for clinical providers. The high-risk threshold was set a priori. Timing and sensitivity of electronic Cardiac Arrest Risk Triage score activation were compared with standard-of-care Rapid Response Team activation for patients who experienced a ward cardiac arrest or ICU transfer. SETTING Three general care wards at an academic medical center. PATIENTS A total of 3,889 adult inpatients. MEASUREMENTS AND MAIN RESULTS The system generated 5,925 segments during 5,751 admissions. The area under the receiver operating characteristic curve for electronic Cardiac Arrest Risk Triage score was 0.88 for cardiac arrest and 0.80 for ICU transfer, consistent with previously published derivation results. During the study period, eight of 10 patients with a cardiac arrest had high-risk electronic Cardiac Arrest Risk Triage scores, whereas the Rapid Response Team was activated on two of these patients (p < 0.05). Furthermore, electronic Cardiac Arrest Risk Triage score identified 52% (n = 201) of the ICU transfers compared with 34% (n = 129) by the current system (p < 0.001). Patients met the high-risk electronic Cardiac Arrest Risk Triage score threshold a median of 30 hours prior to cardiac arrest or ICU transfer versus 1.7 hours for standard Rapid Response Team activation. CONCLUSIONS Electronic Cardiac Arrest Risk Triage score identified significantly more cardiac arrests and ICU transfers than standard Rapid Response Team activation and did so many hours in advance.
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Carberry J, Couper K, Yeung J. The implementation of cardiac arrest treatment recommendations in English acute NHS trusts: a national survey. Postgrad Med J 2017; 93:653-659. [PMID: 28442620 PMCID: PMC5740541 DOI: 10.1136/postgradmedj-2016-134732] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 03/23/2017] [Accepted: 04/02/2017] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
| | - Keith Couper
- Warwick Medical School, University of Warwick, Coventry, UK.,Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Joyce Yeung
- University of Birmingham, Edgbaston, Birmingham, UK.,Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Heart of England NHS Foundation Trust, Birmingham, UK
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Bhardwaj A, Ikeda DJ, Grossestreuer AV, Sheak KR, Delfin G, Layden T, Abella BS, Leary M. Factors associated with re-arrest following initial resuscitation from cardiac arrest. Resuscitation 2016; 111:90-95. [PMID: 27992736 DOI: 10.1016/j.resuscitation.2016.12.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 12/06/2016] [Accepted: 12/09/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND To examine patient- and arrest-level factors associated with the incidence of re-arrest in the hospital setting, and to measure the association between re-arrest and survival to discharge. METHODS This work represents a retrospective cohort study of adult patients who were successfully resuscitated from an initial out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (ICHA) of non-traumatic origin at two urban academic medical centers. In this study, re-arrest was defined as loss of a pulse following 20min of sustained return of spontaneous circulation (ROSC). RESULTS Between 01/2005 and 04/2016, 1961 patients achieved ROSC following non-traumatic cardiac arrest. Of those, 471 (24%) experienced at least one re-arrest. In re-arrest patients, the median time from initial ROSC to first re-arrest was 5.4h (IQR: 1.1, 61.8). The distribution of initial rhythms between single- and re-arrest patients did not vary, nor did the median duration of initial arrest. Among 108 re-arrest patients with an initial shockable rhythm, 60 (56%) experienced a shockable re-arrest rhythm. Among 273 with an initial nonshockable rhythm, 31 (11%) experienced a shockable re-arrest rhythm. After adjusting for significant covariates, the incidence of re-arrest was associated with a lower likelihood of survival to discharge (OR: 0.32; 95% CI: 0.24-0.43; p<0.001). CONCLUSIONS Re-arrest is a common complication experienced by cardiac arrest patients that achieve ROSC, and occurs early in the course of their post-arrest care. Moreover, re-arrest is associated with a decreased likelihood of survival to discharge, even after adjustments for relevant covariates.
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Affiliation(s)
- Abhishek Bhardwaj
- Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA; Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Daniel J Ikeda
- Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anne V Grossestreuer
- Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kelsey R Sheak
- Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gail Delfin
- Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy Layden
- Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin S Abella
- Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marion Leary
- Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA; School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.
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Dolmatova EV, Moazzami K, Klapholz M, Kothari N, Feurdean M, Waller AH. Impact of Hospital Teaching Status on Mortality, Length of Stay and Cost Among Patients With Cardiac Arrest in the United States. Am J Cardiol 2016; 118:668-72. [PMID: 27378144 DOI: 10.1016/j.amjcard.2016.05.062] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 05/24/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
Abstract
Limited data exist regarding the in-hospital outcomes in patients with cardiac arrest (CA) in teaching versus nonteaching hospital settings. Using the Nationwide (National) Inpatient Sample (2008 to 2012), 731,107 cases of CA were identified using International Classification of Diseases, Ninth Edition codes. Among these patients, 348,368 (47.6%) were managed in teaching hospitals and 376,035 (51.4%) in nonteaching hospitals. Patients in teaching hospitals with CA were younger (62.42 vs 68.08 years old), had less co-morbidities (p <0.001), were less likely to be white (54.6% vs 65.5%) and more likely to be uninsured (9.1% vs 7.6%). Mortality in patients with CA was significantly lower in teaching hospitals than in nonteaching hospitals (55.3% vs 58.8%; all p <0.001). The mortality remained significantly lower after adjusting for baseline patient and hospital characteristics (odds ratio 0.917, CI 0.899 to 0.937, p <0.001). However, the survival benefit was no longer present after adjusting for in-hospital procedures (OR 0.997, CI 0.974 to 1.02, p = 0.779). In conclusion, teaching status of the hospital was associated with decreased in-hospital mortality in patients with CA. The differences in mortality disappeared after adjusting for in-hospital procedures, indicating that routine application of novel therapeutic methods in patients with CA in teaching hospitals could translate into improved survival outcomes.
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Xu J, Li C, Li Y, Walline J, Zheng L, Fu Y, Yao D, Zhu H, Liu X, Chai Y, Wang Z, Yu X. Influence of Chest Compressions on Circulation during the Peri-Cardiac Arrest Period in Porcine Models. PLoS One 2016; 11:e0155212. [PMID: 27168071 PMCID: PMC4864302 DOI: 10.1371/journal.pone.0155212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 04/26/2016] [Indexed: 11/18/2022] Open
Abstract
Objective Starting chest compressions immediately after a defibrillation shock might be harmful, if the victim already had a return of spontaneous circulation (ROSC) and yet was still being subjected to external compressions at the same time. The objective of this study was to study the influence of chest compressions on circulation during the peri-cardiac arrest period. Design Prospective, randomized controlled study. Setting Animal experimental center in Peking Union Medical Collage Hospital, Beijing, China. Subjects Healthy 3-month-old male domestic pigs. Interventions 44 pigs (28±2 kg) were randomly assigned to three groups: Group I (non-arrested with compressions) (n = 12); Group II (arrested with compressions only) (n = 12); Group III (ROSC after compressions and defibrillation) (n = 20). In Groups I and II, compressions were performed to a depth of 5cm (Ia and IIa, n = 6) or a depth of 3cm (Ib and IIb, n = 6) respectively, while in Group III, the animals which had just achieved ROSC (n = 18) were compressed to a depth of 5cm (IIIa, n = 6), a depth of 3cm (IIIb, n = 6), or had no compressions (IIIc, n = 6). Hemodynamic parameters were collected and analyzed. Measurements and Findings Hemodynamics were statistically different between Groups Ia and Ib when different depths of compressions were performed (p < 0.05). In Group II, compressions were beneficial and hemodynamics correlated with the depth of compressions (p < 0.05). In Group III, compressions that continued after ROSC produced a reduction in arterial pressure (p < 0.05). Conclusions Chest compressions might be detrimental to hemodynamics in the early post-ROSC stage. The deeper the compressions were, the better the effect on hemodynamics during cardiac arrest, but the worse the effect on hemodynamics after ROSC.
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Affiliation(s)
- Jun Xu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Chen Li
- Emergency Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Yan Li
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Joseph Walline
- Division of Emergency Medicine, Department of Surgery, Saint Louis University Hospital, Saint Louis, Missouri, United States of America
| | - Liangliang Zheng
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yangyang Fu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Dongqi Yao
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaohe Liu
- Emergency Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Yanfen Chai
- Emergency Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhong Wang
- Emergency Department, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- * E-mail:
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Shah NS, Ridgway JP, Pettit N, Fahrenbach J, Robicsek A. Documenting Penicillin Allergy: The Impact of Inconsistency. PLoS One 2016; 11:e0150514. [PMID: 26981866 PMCID: PMC4794183 DOI: 10.1371/journal.pone.0150514] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/15/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Allergy documentation is frequently inconsistent and incomplete. The impact of this variability on subsequent treatment is not well described. OBJECTIVE To determine how allergy documentation affects subsequent antibiotic choice. DESIGN Retrospective, cohort study. PARTICIPANTS 232,616 adult patients seen by 199 primary care providers (PCPs) between January 1, 2009 and January 1, 2014 at an academic medical system. MAIN MEASURES Inter-physician variation in beta-lactam allergy documentation; antibiotic treatment following beta-lactam allergy documentation. KEY RESULTS 15.6% of patients had a reported beta-lactam allergy. Of those patients, 39.8% had a specific allergen identified and 22.7% had allergic reaction characteristics documented. Variation between PCPs was greater than would be expected by chance (all p<0.001) in the percentage of their patients with a documented beta-lactam allergy (7.9% to 24.8%), identification of a specific allergen (e.g. amoxicillin as opposed to "penicillins") (24.0% to 58.2%) and documentation of the reaction characteristics (5.4% to 51.9%). After beta-lactam allergy documentation, patients were less likely to receive penicillins (Relative Risk [RR] 0.16 [95% Confidence Interval: 0.15-0.17]) and cephalosporins (RR 0.28 [95% CI 0.27-0.30]) and more likely to receive fluoroquinolones (RR 1.5 [95% CI 1.5-1.6]), clindamycin (RR 3.8 [95% CI 3.6-4.0]) and vancomycin (RR 5.0 [95% CI 4.3-5.8]). Among patients with beta-lactam allergy, rechallenge was more likely when a specific allergen was identified (RR 1.6 [95% CI 1.5-1.8]) and when reaction characteristics were documented (RR 2.0 [95% CI 1.8-2.2]). CONCLUSIONS Provider documentation of beta-lactam allergy is highly variable, and details of the allergy are infrequently documented. Classification of a patient as beta-lactam allergic and incomplete documentation regarding the details of the allergy lead to beta-lactam avoidance and use of other antimicrobial agents, behaviors that may adversely impact care quality and cost.
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Affiliation(s)
- Nirav S. Shah
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
- * E-mail:
| | - Jessica P. Ridgway
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Natasha Pettit
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - John Fahrenbach
- Department of Clinical Analytics, Northshore University HealthSystem, Evanston, Illinois, United States of America
| | - Ari Robicsek
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
- Department of Clinical Analytics, Northshore University HealthSystem, Evanston, Illinois, United States of America
- Department of Medicine, Northshore University HealthSystem, Evanston, Illinois, United States of America
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Approaches for Therapeutic Temperature Management. JOURNAL OF INFUSION NURSING 2016; 39:26-9. [DOI: 10.1097/nan.0000000000000146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Leary M, Blewer AL, Delfin G, Abella BS. Variability in Postarrest Targeted Temperature Management Practice: Implications of the 2015 Guidelines. Ther Hypothermia Temp Manag 2015; 5:184-7. [PMID: 26642933 PMCID: PMC4677534 DOI: 10.1089/ther.2015.0027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
In 2002 postarrest care was significantly altered when multiple randomized controlled trials found that therapeutic hypothermia at a goal temperature of 32-34°C significantly improved survival and neurologic outcomes. In 2013, targeted temperature management (TTM) was reexamined via a randomized controlled trial between 33°C and 36°C in post-cardiac arrest patients and found similar outcomes in both cohorts. Before the release of the 2015 American Heart Association (AHA) Guidelines, our group found that across hospitals in the United States, and even within the same institution, TTM protocol variability existed. After the 2013 TTM trial, it was anticipated that the 2015 Guidelines would clarify which target temperature should be used during postarrest care. The AHA released their updates for post-cardiac arrest TTM recently and, based on the literature available, have recommended the use of TTM at a goal temperature between 32°C and 36°C. Whether this variability has an effect on TTM implementation or patient outcomes is unknown.
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Affiliation(s)
- Marion Leary
- 1 Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
- 2 School of Nursing, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Audrey L Blewer
- 1 Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
- 3 Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Gail Delfin
- 1 Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Benjamin S Abella
- 1 Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
- 4 Section of Pulmonary Allergy and Critical Care, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
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Kronick SL, Kurz MC, Lin S, Edelson DP, Berg RA, Billi JE, Cabanas JG, Cone DC, Diercks DB, Foster J(J, Meeks RA, Travers AH, Welsford M. Part 4: Systems of Care and Continuous Quality Improvement. Circulation 2015; 132:S397-413. [DOI: 10.1161/cir.0000000000000258] [Citation(s) in RCA: 191] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Xu J, Li C, Zheng L, Han F, Li Y, Walline J, Fu Y, Yao D, Zhang X, Zhang H, Zhu H, Guo S, Wang Z, Yu X. Pulse Oximetry: A Non-Invasive, Novel Marker for the Quality of Chest Compressions in Porcine Models of Cardiac Arrest. PLoS One 2015; 10:e0139707. [PMID: 26485651 PMCID: PMC4613139 DOI: 10.1371/journal.pone.0139707] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/16/2015] [Indexed: 11/18/2022] Open
Abstract
Objective Pulse oximetry, which noninvasively detects the blood flow of peripheral tissue, has achieved widespread clinical use. We have noticed that the better the quality of cardiopulmonary resuscitation (CPR), the better the appearance of pulse oximetry plethysmographic waveform (POP). We investigated whether the area under the curve (AUC) and/or the amplitude (Amp) of POP could be used to monitor the quality of CPR. Design Prospective, randomized controlled study. Setting Animal experimental center in Peking Union Medical Collage Hospital, Beijing, China. Subjects Healthy 3-month-old male domestic swine. Interventions 34 local pigs were enrolled in this study. After 4 minutes of untreated ventricular fibrillation, animals were randomly assigned into two resuscitation groups: a “low quality” group (with a compression depth of 3cm) and a “high quality” group (with a depth of 5cm). All treatments between the two groups were identical except for the depth of chest compressions. Hemodynamic parameters [coronary perfusion pressure (CPP), partial pressure of end-tidal carbon dioxide (PETCO2)] as well as AUC and Amp of POP were all collected and analyzed. Measurements and Findings There were statistical differences between the “high quality” group and the “low quality” group in AUC, Amp, CPP and PETCO2 during CPR (P<0.05). AUC, Amp and CPP were positively correlated with PETCO2, respectively (P<0.01). There was no statistical difference between the heart rate calculated according to the POP (FCPR) and the frequency of mechanical CPR at the 3rd minute of CPR. The FCPR was lower than the frequency of mechanical CPR at the 6th and the 9th minute of CPR. Conclusions Both the AUC and Amp of POP correlated well with CPP and PETCO2 in animal models. The frequency of POP closely matched the CPR heart rate. AUC and Amp of POP might be potential noninvasive quality monitoring markers for CPR.
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Affiliation(s)
- Jun Xu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical sciences, Beijing, China
| | - Chen Li
- Emergency Department, Tianjin Medical University General Hospital, Tianjin, China
| | | | - Fei Han
- Institute of Life Monitoring, Mindray Corporation, Shenzhen, China
| | - Yan Li
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical sciences, Beijing, China
| | - Joseph Walline
- Division of Emergency Medicine, Department of Surgery, Saint Louis University Hospital, Saint Louis, Missouri, United States of America
| | - Yangyang Fu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical sciences, Beijing, China
| | - Dongqi Yao
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical sciences, Beijing, China
| | - Xiaocui Zhang
- Institute of Life Monitoring, Mindray Corporation, Shenzhen, China
| | - Hui Zhang
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical sciences, Beijing, China
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical sciences, Beijing, China
| | - Shubin Guo
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical sciences, Beijing, China
| | - Zhong Wang
- Emergency Department, Beijing Tsinghua Chang Gung Hospital, Beijing, China
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical sciences, Beijing, China
- * E-mail:
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Visual assessment of CPR quality during pediatric cardiac arrest: does point of view matter? Resuscitation 2015; 90:50-5. [PMID: 25727057 DOI: 10.1016/j.resuscitation.2015.01.036] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 01/16/2015] [Accepted: 01/28/2015] [Indexed: 11/21/2022]
Abstract
AIM In many clinical settings, providers rely on visual assessment when delivering feedback on CPR quality. Little is known about the accuracy of visual assessment of CPR quality. We aimed to determine how accurate pediatric providers are in their visual assessment of CPR quality and to identify the optimal position relative to the patient for accurate CPR assessment. METHODS We videotaped high-quality CPR (based on 2010 American Heart Association guidelines) and 3 variations of poor quality CPR in a simulated resuscitation, filmed from the foot, head and the side of the manikin. Participants watched 12 videos and completed a questionnaire to assess CPR quality. RESULTS One hundred and twenty-five participants were recruited. The overall accuracy of visual assessment of CPR quality was 65.6%. Accuracy was better from the side (70.8%) and foot (68.8%) of the bed when compared to the head of the bed (57.2%; p<0.001). The side was the best position for assessing depth (p<0.001). Rate assessment was equivalent between positions (p=0.58). The side and foot of the bed were superior to the head when assessing chest recoil (p<0.001). Factors associated with increased accuracy in visual assessment of CPR quality included recent CPR course completion (p=0.034) and involvement in more cardiac arrests as a team member (p=0.003). CONCLUSION Healthcare providers struggle to accurately assess the quality of CPR using visual assessment. If visual assessment is being used, providers should stand at the side of the bed.
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Cheng A, Overly F, Kessler D, Nadkarni VM, Lin Y, Doan Q, Duff JP, Tofil NM, Bhanji F, Adler M, Charnovich A, Hunt EA, Brown LL. Perception of CPR quality: Influence of CPR feedback, Just-in-Time CPR training and provider role. Resuscitation 2015; 87:44-50. [DOI: 10.1016/j.resuscitation.2014.11.015] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 11/11/2014] [Accepted: 11/18/2014] [Indexed: 10/24/2022]
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O'Leary KJ, Didwania AK. Rapid response teams in teaching hospitals: aligning efforts to improve medical education and quality. J Hosp Med 2015; 10:62-3. [PMID: 25603792 DOI: 10.1002/jhm.2294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 11/04/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Kevin J O'Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Lin Y, Cheng A. The role of simulation in teaching pediatric resuscitation: current perspectives. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2015; 6:239-48. [PMID: 25878517 PMCID: PMC4388005 DOI: 10.2147/amep.s64178] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
The use of simulation for teaching the knowledge, skills, and behaviors necessary for effective pediatric resuscitation has seen widespread growth and adoption across pediatric institutions. In this paper, we describe the application of simulation in pediatric resuscitation training and review the evidence for the use of simulation in neonatal resuscitation, pediatric advanced life support, procedural skills training, and crisis resource management training. We also highlight studies supporting several key instructional design elements that enhance learning, including the use of high-fidelity simulation, distributed practice, deliberate practice, feedback, and debriefing. Simulation-based training is an effective modality for teaching pediatric resuscitation concepts. Current literature has revealed some research gaps in simulation-based education, which could indicate the direction for the future of pediatric resuscitation research.
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Affiliation(s)
- Yiqun Lin
- KidSIM-ASPIRE Simulation Research Program, Alberta Children’s Hospital, University of Calgary, Calgary, AB, Canada
| | - Adam Cheng
- KidSIM-ASPIRE Research Program, Department of Pediatrics, Division of Emergency Medicine, University of Calgary, Alberta Children’s Hospital, Calgary, AB, Canada
- Correspondence: Adam Cheng, KidSim-ASPIRE Research Program, Department of Pediatrics, Division of Emergency Medicine, University of Calgary, Alberta Children’s Hospital, 2888 Shaganappi Trail NW, Calgary, AB T3B 6A8, Canada, Tel +1 403 955 2633, Fax +1 403 955 7552 (attention – Luisa Steen), Email
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Stockmann H, Krannich A, Schroeder T, Storm C. Therapeutic temperature management after cardiac arrest and the risk of bleeding: systematic review and meta-analysis. Resuscitation 2014; 85:1494-503. [PMID: 25132475 DOI: 10.1016/j.resuscitation.2014.07.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 07/23/2014] [Accepted: 07/27/2014] [Indexed: 10/24/2022]
Abstract
AIM Prognosis after cardiac arrest in the era of modern critical care is still poor with a high mortality of approximately 90%. Around 30% of the survivors have neurological impairments. Targeted temperature management (TTM) is the only treatment option which can improve mortality and neurological outcome. It is so far unclear if bleeding complications occur more often in patients undergoing TTM treatment. METHODS We conducted a systematic literature research in September 2013 including three major databases i.e. MEDLINE, EMBASE and CENTRAL. All studies were rated in respect to the ILCOR Guidelines and concerning their level of evidence and quality. We then performed a meta-analysis on bleeding disposition under TTM. RESULTS We initially found 941 studies out of which 34 matched our requirements and were thus included in our overview. Five studies including 599 patients were summarized in a meta-analysis concerning bleeding complications of all severities. There was a trend toward higher bleeding in patients treated with TTM (RR: 1.30, 95% CI: 0.97-1.74) which did not reach significance (p=0.085). Seven studies with an overall 599 patients were included in our meta-analysis on bleeding requiring transfusion. There was no significant difference in the incidence of severe bleeding with a risk ratio of 0.97 (95% CI: 0.61-1.56, p=0.909). CONCLUSIONS The data included in our meta-analysis indicate that, concerning the risk of bleeding, TTM is a safe method for patients after cardiac arrest. We did not observe a significantly higher risk for bleeding in patients undergoing TTM.
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Affiliation(s)
- Helena Stockmann
- Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Department of Nephrology and Medical Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Alexander Krannich
- Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Coordination Center for Clinical Trials, Department of Biostatistics, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Tim Schroeder
- Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Department of Nephrology and Medical Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Christian Storm
- Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Department of Nephrology and Medical Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
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