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

Harrison D, Hossain A, Lall R, Mason J, Nolan JP, Nwankwo H, Perkins GD, Samuel K, Schofield B, Soar J, Starr K, Thomas M, Voss S, Benger JR. Randomised trial of the clinical and cost effectiveness of a supraglottic airway device compared with tracheal intubation for in-hospital cardiac arrest (AIRWAYS-3): Protocol, design and implementation

Survival from in-hospital cardiac arrest is approximately 18%, but for patients who require advanced airway management survival is lower. Those who do survive are often left with significant disability. Traditionally, resuscitation of cardiac arrest patients has included tracheal intubation, however insertion of a supraglottic airway has gained popularity as an alternative approach to advanced airway management. Evidence from out-of-hospital cardiac arrest suggests no significant differences in mortality or morbidity between these two approaches, but there is no randomised evidence for airway management during in-hospital cardiac arrest. The aim of the AIRWAYS-3 randomised trial, described in this protocol paper, is to determine the clinical and cost effectiveness of a supraglottic airway versus tracheal intubation during in-hospital cardiac arrest. Patients will be allocated randomly to receive either a supraglottic airway or tracheal intubation as the initial advanced airway management. We will also estimate the relative cost-effectiveness of these two approaches. The primary outcome is functional status, measured using the modified Rankin Scale at hospital discharge or 30 days post-randomisation, whichever occurs first. AIRWAYS-3 presents ethical challenges regarding patient consent and data collection. These include the enrolment of unconscious patients without prior consent in a way that avoids methodological bias. Other complexities include the requirement to randomise patients efficiently during a time-critical cardiac arrest. Many of these challenges are encountered in other emergency care research; we discuss our approaches to addressing them. Trial registration: ISRCTN17720457. Prospectively registered on 29/07/2022.

Improving Usability of the Pediatric Code Cart by Combining Lean and Human Factors Principles

Cardiac arrests are common in hospitalized children. Well-organized code carts are needed during these events to help staff efficiently find supplies and medications for the patient. This study aimed to improve the efficiency and utilization of the code cart at a major academic pediatric medical center.

Methods

This quality improvement project used a phased approach to redesign the code cart. A multidisciplinary team used Lean and Human Factors principles to improve the efficiency and intuitiveness of the redesigned cart. Nurses and respiratory therapists participated in simulations asking for certain supplies with the original and redesigned code cart and filled out surveys for feedback on each code cart. Facilitators measured retrieval times during each simulation.

Results

We performed 10 simulations with the original code cart and 13 with the redesigned code cart. Staff could find intraosseous access equipment more quickly (23.9 versus 46.4 seconds; P = 0.003). In addition, staff reported they were less likely to open the wrong drawer or grab the wrong equipment and that the redesigned code cart was overall more well organized than the original code cart. Finally, the redesigned code cart reduced the cost by over 800 dollars per full cart restock.

Conclusion

Revising the code cart using Lean and Human Factors improves efficiency and usability and can contribute to cost savings.

Pediatic code blue event anaylsis: Performance of non-acute health-care providers

In-hospital pediatric cardiopulmonary arrest is rare. With more than 50% of patients not surviving to discharge following cardiopulmonary arrest, it is important that health-care providers (HCPs) respond appropriately to deteriorating patients. Our study evaluated the performance of basic life support skills using non-acute HCPs during pediatric inpatient resuscitation events. We conducted a retrospective chart review of all code blue team (CBT) activations in non-acute care areas of a tertiary care children's hospital from 2008 to 2017. The main outcomes were frequency of life support algorithmic assessments and interventions (critical actions) performed by non-acute HCPs prior to the arrival of CBT. CBT activation and outcome data were summarized descriptively. Logistic regression was used to assess for an association of outcomes with the presence of established leadership. A total of 60 CBT activations were retrieved, 48 of which had data available on isolated non-acute HCP performance. Most children (93%) survived to discharge. Critical action performance review revealed that an airway, breathing and pulse assessment was documented to have occurred in 33%, 69% and 29% of cases, respectively. A full primary assessment was documented in 6% of cases. The presence of established leadership was associated with the performance of a partial ABC assessment. Our results suggest that resuscitation performance of pediatric inpatient non-acute HCPs often does not adhere to standard life support guidelines. These results highlight the need to reconsider the current approaches used for non-acute HCP resuscitation training.

Improving Resuscitation Timing: Random Assignment of Interprofessional Team Leaders in Simulated Resuscitation

OBJECTIVES

The aims of the study were to assess whether preassigning a team leader influences resuscitation timing using simulation and to examine relationship between response timeliness and designated leader's profession, whether physician or nurse.

METHODS

This is a prospective study of intervention (leader assigned) and control (no assigned leader) teams of residents and nurses participating in a simulated scenario. The primary outcome was time to bag-valve-mask (BVM) ventilation. A secondary outcome measure compared difference in time to BVM between physician- and nurse-led teams.

RESULTS

We assessed 25 teams, leader assigned (n = 14) or control (n = 11), composed of 92 clinicians. Leaders emerged in most of the controls (10 of 11). The median time to BVM in the leader-assigned group was 41.5 seconds (interquartile range, 34-49 seconds) compared with 53 seconds (interquartile range, 27-85 seconds) for controls (P = 0.13). In the leader-assigned group, 85% (12 of 14) of teams initiated BVM in less than 1 minute compared with only 54% teams (6 of 11) in controls (P = 0.18). Among the leader-assigned teams, we randomly assigned residents to lead 8 teams and nurses to lead 6 teams. All the nurse-led teams (6 of 6) initiated BVM in less than 1 minute compared with fewer physician-led teams (6 of 8) and only approximately half of controls (6 of 11, P = 0.19).

CONCLUSIONS

The leader-assigned teams and controls did not differ in resuscitation timeliness. Among leader-assigned teams, the differences in time to BVM between physician- and nurse-led teams were not statistically significant. However, all 6 nurse-led teams demonstrated timely resuscitation, suggesting a direction for future research on the feasibility of bedside nurses taking the lead during resuscitation, pending code team arrival.

Public attitudes towards cardiopulmonary resuscitation training and performance in Singapore

Background

Bystander cardiopulmonary resuscitation (CPR) rates remain fairly low through most communities despite multiple interventions through the years. Understanding the attitudes and fears behind CPR training and performance would help target education and training to raise the rates of bystander CPR and consequently survival rates of victims. 7909 participants at a single-day mass CPR training session in Singapore were given survey questionnaires to fill out. 6473 people submitted completed forms upon the conclusion of the training session. Some issues looked at were the overall level of difficulty of CPR, difficulty levels of specific skills, attitudes towards refresher training, attitudes towards performing CPR, and fears when doing so.

Results

The mean level of difficulty of CPR was rated 3.98 (scale of 1–10), with those with previous CPR training rating it easier. The skills rated most difficult were performing mouth-to-mouth breathing and chest compressions, while the easiest rated was recognizing non-responsiveness. A majority (69.7%) would agree to go for refresher training every 2 years and 88.7% felt everyone should be trained in CPR. 71.6% would perform full CPR for a member of the public in cardiac arrest and only 20.7% would prefer to only do chest compressions. The most cited fear was a low level of confidence, and fears of acquiring infections or aversion to mouth-to-mouth breathing were low.

Conclusions

The survey results show that most participants in Singapore are keen to perform conventional CPR for a member of the public and can help to target future CPR training accordingly.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12245-021-00378-1.

Development and pilot of an interprofessional pediatric resuscitation program for non-acute care inpatient providers

Multiprofessional ward healthcare providers are generally unprepared to assemble and engage in the initial resuscitation of pediatric inpatients. This is important as the performance of these first-responders, in the several minutes prior to the arrival of acute care support, may have significant effects on overall patient outcome. Accordingly, we aimed to develop and pilot a training program intended for non-acute care inpatient providers, relevant to their working context. Using the latest theory and evidence in medical education, we created an interprofessional, entirely in-situ, simulation-based small-group activity. The activity was then piloted for four months with the goals of assessing perceived usefulness, as well as implementation factors such as participant accessibility and overall resource requirements. A total of 37 interprofessional (physician and nursing) staff were trained in 16 small group sessions over four months. Post-participation questionnaires revealed that the activity was perceived to be highly useful for their practice; especially the rapid cycle deliberate practice instructional method, and the increased focus on crisis resource management. Resource requirements were comparable to, and perhaps less than, existing acute care training programs. This project describes the preliminary steps taken in creating a curriculum intended to improve interprofessional resuscitation performance across an institution.

The Impact of Monitoring on the Initiation of Cardiopulmonary Resuscitation in Children: Friend or Foe?

BACKGROUND

The immediate initiation and high quality of basic life support (BLS) are pivotal to improving patient outcome after cardiac arrest. Although cardiorespiratory monitoring could shorten the time to recognize the onset of cardiac arrest, little is known about how monitoring and the misinterpretation of monitor readings could impair the initiation of BLS. In this study, we assessed the speed of initiation and quality of BLS in simulated monitored and nonmonitored pediatric cardiac arrest.

METHODS

Sixty residents frequently involved in the care of critically ill children were randomly assigned to either the intervention (monitoring) group or the control (nonmonitoring) group. Participants of both groups performed BLS in 1 of 2 clinically identical, unwitnessed simulated cardiac arrest scenarios. Although in 1 scenario cardiorespiratory monitoring (i.e., electrocardiogram) was attached, the other scenario reflected a nonmonitored cardiac arrest. Time to first chest compression was chosen as the primary outcome variable. Adherence to resuscitation guidelines and subjective performance ratings were secondary outcome variables.

RESULTS

Participants in the monitoring group initiated chest compressions significantly later than those in the nonmonitoring group (91 ± 36 vs 71 ± 26 seconds, hazard ratio, 0.26; 95% confidence interval, 0.14-0.49, P < 0.001). Six members of the monitoring group did not start chest compression within 5 minutes. Furthermore, adherence to the guidelines was better in the nonmonitoring group. Participants who were previously involved in BLS training did not show better performance.

CONCLUSIONS

The presence of cardiorespiratory monitoring significantly delayed or even prevented the initiation of chest compressions and impaired the quality of BLS in simulated pediatric cardiac arrest. Based on these data, specific training should be conducted for exposed personnel.

"ABC-SBAR" training improves simulated critical patient hand-off by pediatric interns

OBJECTIVES

This study was done to assess whether a modified "ABC-SBAR" mnemonic (airway, breathing, circulation followed by situation, background, assessment, and recommendation) improves hand-offs by pediatric interns in a simulated critical patient scenario.

METHODS

Each of 26 interns reviewed a scenario involving a decompensating pediatric patient and gave a simulated hand-off to a responder. They received a didactic session on ABC-SBAR, then performed a second hand-off using another scenario. Two blinded reviewers assessed 52 video-recorded hand-offs for inclusion, order, and elapsed time to essential hand-off information using a scoring tool.

RESULTS

Mean score of hand-offs increased after ABC-SBAR training (preintervention: 3.1/10 vs postintervention: 7.8/10, P < 0.001). In hand-offs after ABC-SBAR training, the reason for the emergency call was more often prioritized before background information (preintervention: 4% vs postintervention: 81%, P < 0.001) and stated earlier (elapsed time preintervention: 19 seconds vs postintervention: 7 seconds, P < 0.001). Hand-offs including an airway or breathing assessment increased after training (preintervention: 35% vs postintervention: 85%, P = 0.001), and this information was also stated earlier (preintervention: 25 seconds vs postintervention: 5 seconds, P < 0.001). Total hand-off duration was increased (preintervention: 29 seconds vs postintervention: 36 seconds, P = 0.004).

CONCLUSIONS

Unstructured hand-off by interns in a simulated patient emergency emphasizes background information, leaving essential information (such as reason for the call and ABCs) delayed or omitted. ABC-SBAR was associated with improved inclusion and timeliness of essential information in simulated critical patient hand-offs by pediatric interns; however, hand-off duration was increased. Further studies are needed to elucidate optimal hand-off in an emergency situation.

Improving medication management through the redesign of the hospital code cart medication drawer

OBJECTIVE

This study utilized usability testing and human factors engineering (HFE) principles to create efficient code cart medication drawer modifications to improve code blue medical emergency (code) medication management.

BACKGROUND

Effective access to medications during a code is a key component in delivering optimal care and has been found to be a major problem among health care organizations; however, little research has been conducted to improve the efficiency of medication management during a code.

METHOD

A total of 26 health care professionals (13 pharmacists and 13 nurses) were asked to locate items within a code cart medication drawer during two independent simulated code scenarios alternately using either a baseline medication drawer (control; Drawer 1) or a prototype medication drawer (prototype; Drawer 2), which was developed using HFE principles and usability testing. Overall medication retrieval time, wasteful actions, and survey responses were recorded.

RESULTS

Drawer 2 had significantly faster trial completion times (p = .005) and fewer wasteful actions (p < .001) compared to Drawer 1. Participant survey results rated Drawer 2 (prototype) significantly higher (more favorable) for medication drawer visibility (p < .001), usability (p = .011), and organization (p < .001) compared to Drawer I (baseline).

CONCLUSION

The HFE redesign concepts incorporated into Drawer 2 (consisting of visibility, grouping, and organization) produced successful, low-cost, and generalizable modifications that can improve patient care.

APPLICATION

The findings demonstrate that HFE and usability applied to code cart design are effective, are customizable, and can affect patient safety by saving valuable time and reducing wasted motions (including errors) during code situations.

Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes

OBJECTIVES

Outcomes of in-hospital pediatric cardiopulmonary arrest are dismal. Recent data suggest that the quality of basic and advanced life support delivered to adults is low and contributes to poor outcomes, but few data regarding pediatric events have been reported. The objectives of this study were to (1) measure the median elapsed time to initiate important resuscitation maneuvers in simulated pediatric medical emergencies (ie, "mock codes") and (2) identify the types and frequency of errors committed during pediatric mock codes.

METHODS

A prospective, observational study was conducted of 34 consecutive hospital-based mock codes. A mannequin or computerized simulator was used to enact unannounced, simulated crisis situations involving children with respiratory distress or insufficiency, respiratory arrest, hemodynamic instability, and/or cardiopulmonary arrest. Assessment included time elapsed to initiation of specific resuscitation maneuvers and deviation from American Heart Association guidelines.

RESULTS

Among the 34 mock codes, the median time to assessment of airway and breathing was 1.3 minutes, to administration of oxygen was 2.0 minutes, to assessment of circulation was 4.0 minutes, to arrival of any physician was 3.0 minutes, and to arrival of first member of code team was 6.0 minutes. Among cardiopulmonary arrest scenarios, elapsed time to initiation of compressions was 1.5 minutes and to request for defibrillator was 4.3 minutes. In 75% of mock codes, the team deviated from American Heart Association pediatric basic life support protocols, and in 100% of mock codes there was a communication error.

CONCLUSIONS

Alarming delays and deviations occur in the major components of pediatric resuscitation. Future educational and organizational interventions should focus on improving the quality of care delivered during the first 5 minutes of resuscitation. Simulation of pediatric crises can identify targets for educational intervention to improve pediatric cardiopulmonary resuscitation and, ideally, outcomes.

Improved basic life support performance by ward nurses using the CAREvent® Public Access Resuscitator (PAR) in a simulated setting

INTRODUCTION

The CAREvent Public Access Resuscitator (PAR, O-Two Medical Technologies, Ontario, Canada) is a new oxygen-driven device alternating two ventilations with 15 prompts for chest compressions. The PAR is designed for use with a standard resuscitation face mask and is equipped with mask leakage and obstruction alarms. The purpose of this study was to assess the quality of basic life support (BLS) by hospital nurses and to evaluate if BLS with the PAR is better than BLS using the mouth-to-mask technique.

METHODS

The study group consisted of 352 nurses from Ghent University Hospital working outside the critical care and emergency departments. BLS skills were measured using a Laerdal Skillreporter manikin (Laerdal, Norway) connected to a Laerdal PC Skillreporting system. To assess base line skills, 200 nurses were tested without previous notice in single rescuer BLS using a pocket mask (PM, Laerdal, Norway) or a bag-valve mask device (Laerdal, Norway) over a period of 2 min. A separate consecutive sample of 152 nurses was randomised to the PM or PAR groups after a standard BLS refresher course. The PAR group received a short period of training in PAR use. Immediately after training, both groups performed the 2 min single rescuer BLS test.

RESULTS

Unprepared nurses achieved only 26 compressions and 3 ventilations/min. Immediately after training, nurses using the PAR delivered 54 compressions/min as opposed to 35 for the PM group (p<0.0001). PAR users ventilated six times/min compared to five times for PM users (p<0.0001).

CONCLUSION

Immediately after training, the use of the PAR improved BLS performance by ward nurses significantly, bringing the number of ventilations and compressions per minute close to the theoretical maximum achievable within the current guidelines. Retention tests after 6 and 12 months will show if the effect is sustained.

Performance of an automatic external cardioverter-defibrillator algorithm in the discrimination of supraventricular from ventricular tachycardia

An automatic external cardioverter-defibrillator (AECD) with a programmable supraventricular-ventricular tachycardia (VT) zone underwent evaluation of arrhythmia discrimination performance in the electrophysiologic laboratory during induced supraventricular tachycardia (SVT) and unipolar and bipolar atrial pacing. The AECD SVT zone was programmed so that the induced SVT rate would fall within this zone. Atrial pacing was also performed at a rate within this zone. The ability of the AECD to accurately discriminate between VT and SVT and to recommend shock delivery was assessed. A total of 98 patients underwent conventional diagnostic electrophysiologic studies (49 men, age 59 +/- 19 years) with a total of 55 inducible sustained SVTs. High right atrial pacing was performed in 56 patients in unipolar and in 82 patients in bipolar fashion. In response to induced sustained SVT, the AECD correctly classified 47 episodes as nonshockable, 4 incorrectly as shockable, and 4 episodes correctly as shockable with a resultant sensitivity of 100% and specificity of 92%. Bipolar high right atrial pacing was correctly identified as nonshockable in 75 episodes, incorrectly identified as shockable in 5 episodes, and correctly identified as shockable in 2 episodes with a resultant sensitivity of 100% and specificity of 94%. The Powerheart AECD accurately discriminates SVT from VT and is expected to correctly deliver automatic external shocks rapidly in the presence of spontaneous life-threatening tachycardia and appropriately withhold therapy during SVT.

The epidemiology of cardiac arrests in a Sydney hospital

AIM

To examine the epidemiology of cardiac arrest (CA) in New South Wales (NSW), Australia, and a large teaching hospital in Sydney and to identify predictors of survival.

METHODS

Data from the 1996/97 NSW inpatient statistics collection were analysed. Logistic regression was used to determine predictors of mortality from CA.

RESULTS

In 1996/97 in public hospitals, Eastern Sydney Area Health Service (AHS) (47.5), and in private hospitals of Macleay-Hastings District Health Services (DHSs), recorded the highest crude CA rates in NSW with figures of 47.5 and 21.3 per 10,000 hospital separations. Standardised CA rates were highest in Western Sydney, Illawara, Macleay-Hasting, Mid North Coast and Orana DHSs. Most CAs in hospital 'X' occurred after admission and 55.7% occurred in patients admitted with a non-cardiac principal diagnosis, mainly pneumonia. Acute myocardial infarction was the leading diagnosis (28.9%) in patients who suffered CA after admission. Only 32% of CA patients survived to discharge. Age above 65 (odds ratio (OR)=2.284, P=0.006) had the highest effect on cardiac mortality. The longer the patients were in the intensive care unit (OR=0.997, P=0.037), the more likely they were to survive.

CONCLUSION

We describe considerable variation in CA rates in NSW. The majority of hospital CAs occur at or soon after admission, and are associated with underlying non-cardiac conditions. Survival following hospital CA is low, but there may be preventable elements. Knowledge of risk factors and epidemiology of hospital CAs may help identify patients at risk of CA.

An improved pocket rescue mask incorporating a novel visual breathing indicator

The difficulties inherent in the 'Look, Listen and Feel' method of identifying respiratory arrest prompted the authors to develop a simple mechanical breathing indicator that can show clearly, at a glance, whether or not a patient is breathing. The novel indicator was designed to be highly visible so that its interpretation should be obvious to medical personnel and the lay public, and yet sufficiently simple so that it could be easily and inexpensively incorporated into the type of pocket rescue masks currently in use. The indicator needs no power source, works indoors and outdoors and does not interfere with the delivery of rescue breaths during resuscitation. A prototype of the improved pocket mask incorporating the new indicator was made and was tested for its ability to detect breaths over a range of inspiratory flow rates and inspiratory pressures. The authors found that the indicator responded to peak inspiratory flow rates of between 15 and 120 l/min, inspiratory pressures as low as 0.18 cm H(2)O with no supplemental oxygen flowing to the mask and 0.22 cm H(2)O with supplemental oxygen flowing at 9 l/min, minute ventilation volumes between 7.1 and 21.8 l/min, tidal volumes between 0.36 and 2.92 l and a respiratory rate range of 7-24 breaths per min. The authors conclude that the new indicator, when attached to a pocket rescue mask, is sensitive enough to identify clearly and reliably those patients at the scene of collapse who have stopped breathing. Additionally it may assist rescuers in timing the delivery of assisted rescue breaths in those patients with poor respiratory effort.

Determinants of physician reluctance to perform mouth-to-mouth resuscitation

OBJECTIVES

Mouth-to-mouth resuscitation (MMR) is widely taught and promoted. The purpose of this study was to better characterize the observation that health professionals are reluctant to perform MMR and to identify determinants of this reluctance.

METHODS

324 residents and faculty at a New York City teaching hospital were anonymously surveyed regarding their reluctance to perform MMR. One year later, medical staff were resurveyed.

RESULTS

Reluctance varied across scenarios: 70-80% of physicians were willing to perform MMR on a newborn or child, 40-50% for an unknown man, and 20-30% for a trauma victim or potentially gay man. Physicians reported very similar percentages for each scenario in the two surveys. Factors associated with MMR reluctance were female gender (OR = 2), resident physician (OR = 2), and higher perceived risk of contracting HIV from MMR (OR = 1.4 per unit on 5-point scale). In the year before the survey, 30% of all respondents witnessed an apneic patient who required MMR for whom ventilation was not provided for at least 2 minutes.

CONCLUSIONS

Many physicians are reluctant to perform MMR. Marked delays in ventilation of apneic patients are occurring.

The incidence of regurgitation during cardiopulmonary resuscitation: a comparison between the bag valve mask and laryngeal mask airway

The risk of gastric regurgitation and subsequent pulmonary aspiration is a recognised complication of cardiac arrest--a risk which may be further increased by the resuscitative procedure itself. The purpose of this study was to compare the incidence of gastric regurgitation between the bag valve mask (BVM) and laryngeal mask airway (LMA). The resuscitation data collection forms of 996 patients who underwent in-hospital cardiopulmonary resuscitation over a 3.5 year period were reviewed. Of these, 199 patients were excluded from the study because there was no airway management involving a BVM or LMA. The incidence and timing of regurgitation was studied in the remaining 797 patients. Regurgitation was recorded to have occurred at some stage in 180 of these patients (22.6%). However, 84 regurgitated prior to CPR (46.7% of those patients who regurgitated). These patients were excluded from further analysis as regurgitation could not have been affected by any form of ventilation. Of the remaining 713 patients, BVM ventilation was used in 636 cases. In 170 of these the LMA was also used following the BVM. Where the patient was ventilated with the BVM alone or BVM followed by ETT the incidence of regurgitation during CPR was 12.4%. The LMA was used during resuscitation in 256 cases of which 170 had BVM ventilation prior to the LMA. Where the patient was ventilated with the LMA alone or LMA followed by ETT the incidence of regurgitation during CPR was 3.5%. The study confirms experience reported in earlier studies that when an LMA is used as a first line airway device, regurgitation is relatively uncommon.

Determinants of reluctance to perform CPR among residents and applicants: the impact of experience on helping behavior

BACKGROUND

Though mouth-to-mouth resuscitation (MMR) is widely endorsed as a useful lifesaving technique, studies have shown that health care professionals are reluctant to perform it. To characterize the circumstances which facilitate this reluctance among physicians, we have surveyed current and future residency trainees regarding attitudes toward providing ventilation by this method to strangers experiencing arrest in the community.

METHODS

A total of 280 categorical emergency medicine (EM) and internal medicine (IM) house officers and respective program applicants at a 655 bed Brooklyn, New York teaching hospital were anonymously surveyed regarding their willingness to attempt resuscitation in five hypothetical scenarios of cardiopulmonary arrest.

RESULTS

A direct relationship was observed between residency training level and reluctance to perform MMR in each scenario. Applicants expressed greater overall willingness to perform MMR than all residents (56 versus 34%, P < 0.00001). Willingness among experienced residents was lower than for junior-level residents (29 versus 40%, P = 0.01). EM and IM physicians were statistically indifferent in their responses. There were no differences in willingness to perform MMR by age in MD applicant or resident groups.

CONCLUSIONS

Many physicians and future doctors are reluctant to perform MMR on arrest victims in the community, a trend that increases in prevalence among those with more residency training. These data support the hypothesis that diminished helping behavior occurs gradually over the training period and may occur as a direct consequence of the training experience. A model for characterizing the elements that make up a rescuer's decision process is proposed.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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