Quality of CPR during advanced resuscitation training

Comparison Between Self-Deliberate Practice and Directed Learning Training Methods for Basic Life Support Knowledge and High-Quality Cardiopulmonary Resuscitation Skill Retention in Second-Year Medical Students 3 and 6 Months After Training

Background

Cardiopulmonary resuscitation (CPR) requires well-trained medical personnel. Multiple learning methods can be done for CPR skills training. This study aimed to compare self-deliberate practice (SDP) method and directed learning (DL) method to improve basic life support (BLS) knowledge and CPR skill performance in medical students.

Methods

This is an experimental, single-blind, randomized controlled trial study of 40 medical students from February to July 2019. Forty subjects were randomly assigned into SDP and DL groups through a voluntary sampling method. Both groups attended a 1-day course and then practiced once a month for 3 months. The DL group had practice sessions with assigned tutors, while the SDP group had to practice by themselves. Examination of BLS knowledge and CPR performance quality (compression depth, rate, and performance score) was collected before and after course lecture, after a skills training, 3 and 6 months after training.

Results

Subject characteristics of both groups were comparable. Significant knowledge and skill improvement were found in the DL group and the SDP group when compared to their knowledge and skill before training. There were no significant differences between both groups in BLS knowledge and CPR performance quality in all examination periods.

Conclusion

Both SDP and DL teaching methods show significant improvement and excellent retention in BLS knowledge and high-quality CPR performance. These two learning methods are both feasible and bring positive results for students.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01746-7.

Effect of real-time feedback device compared to use or non-use of a checklist performance aid on post-training performance and retention of infant cardiopulmonary resuscitation: A randomized simulation-based trial

INTRODUCTION

This study aims to determine the best method for achieving optimal performance of pediatric cardiopulmonary resuscitation (CPR) during simulation-based training, whether with or without a performance aid.

METHODS

In this randomized controlled study, 46 participants performed simulated CPR in pairs on a Resusci Baby QCPR™ mannequin, repeated after four weeks. All participants performed the first simulation without performance aids. For the second simulation, they were randomly assigned to one of three groups with stratification based on status: throughout CPR, Group A (n = 16) was the control group and did not use a performance aid; Group B (n = 16) used the CPR checklist; Group C (n = 14) used real-time visualization of their CPR activity on a feedback device. Overall performance was assessed using the QCPR™.

RESULTS

All groups demonstrated improved performance on the second simulation (p < 0.01). Use of the feedback device resulted in better CPR performance than use of the CPR checklist (p = 0.02) or no performance aid (p = 0.04). Additionally, participants thought that the QCPR™ could effectively improve their technical competences.

CONCLUSIONS

Performance aid based on continuous feedback is helpful in the learning process. The use of the QCPR™, a real-time feedback device, improved the quality of resuscitation during infant CPR simulation-based training.

The implementation of code blue by nurses as first responders in outpatient and inpatient rooms at Malang Indonesia Hospital

Introduction: In-Hospital Cardiac Arrest (IHCA) is a frequent occurrence that necessitates prompt and appropriate assistance to improve survival rates. Nurses in public care rooms and outpatients are expected to be first responders to IHCA until an activated hospital code blue team arrives. Therefore, this study aims to analyze the implementation of code blue response by nurses in outpatient and hospital inpatient rooms in Malang. Design and Methods: This is a quantitative study that uses observational methods with a cross-sectional approach comprising of 109 inpatient and outpatient care room nurses from 9 hospitals in Malang. The implementation of code blue was measured by a simulated case of adult cardiac arrest in a hospital inpatient room. Results: The nurses involved were 67.0% female, where the majority have a D3 education qualification (57.7%), with more than ten years working experience (45%). Furthermore, 83.5% of nurses work in regular care rooms and 16.5% come from outpatient rooms. The results showed that the implementation of code blue by nurses in regular care and inpatient rooms was 66.7% and 65.9%, respectively in the insufficient categories. In addition, the Mann-Whitney U test obtained a p-value of 0.929. Conclusions: In conclusion, there was no significant difference in the implementation of code blue that occurred in the inpatient and outpatient rooms. Further studies were recommended to observe code blue events directly and take samples with balanced proportions.  

The use of a cognitive aid app supports guideline-conforming cardiopulmonary resuscitations: A randomized study in a high-fidelity simulation

Aim

Cardiac arrests require fast, well-timed, and well-coordinated interventions delivered by several staff members. We evaluated a cognitive aid that works as an attentional aid to support specifically the timing and coordination of these interventions. We report the results of an experimental, simulation-based evaluation of the tablet-based cognitive aid in performing guideline-conforming cardiopulmonary resuscitation.

Methods

In a parallel group design, emergency teams (one qualified emergency physician as team leader and one qualified nurse) were randomly assigned to the cognitive aid application (CA App) group or the no application (No App) group and then participated in a simulated scenario of a cardiac arrest. The primary outcome was a cardiopulmonary resuscitation performance score ranging from zero to two for each team based on the videotaped scenarios in relation to twelve performance variables derived from the European Resuscitation Guidelines. As a secondary outcome, we measured the participants’ subjective workload.

Results

A total of 67 teams participated. The CA App group (n = 32 teams) showed significantly better cardiopulmonary resuscitation performance than the No App group (n = 31 teams; mean difference = 0.23, 95 %CI = 0.08 to 0.38, p = 0.002, d = 0.83). The CA App group team leaders indicated significantly less mental and physical demand and less effort to achieve their performance compared to the No App group team leaders.

Conclusions

Among well-trained in-hospital emergency teams, the cognitive aid could improve cardiopulmonary resuscitation coordination performance and decrease mental workload.

The effective group size for teaching cardiopulmonary resuscitation skills - A randomized controlled simulation trial

AIM OF THE STUDY

The ideal group size for effective teaching of cardiopulmonary resuscitation is currently under debate. The upper limit is reached when instructors are unable to correct participants' errors during skills practice. This simulation study aimed to define this limit during cardiopulmonary resuscitation teaching.

METHODS

Medical students acting as simulated Basic Life Support course participants were instructed to make three different pre-defined Basic Life Support quality errors (e.g., chest compression too fast) in 7 min. Basic Life Support instructors were randomized to groups of 3-10 participants. Instructors were asked to observe the Basic Life Support skills and to correct performance errors. Primary outcome was the maximum group size at which the percentage of correctly identified participants' errors drops below 80%.

RESULTS

Sixty-four instructors participated, eight for each group size. Their average age was 41 ± 9 years and 33% were female, with a median [25th percentile; 75th percentile] teaching experience of 6 [2;11] years. Instructors had taught 3 [1;5] cardiopulmonary resuscitation courses in the year before the study. A logistic binominal regression model showed that the predicted mean percentage of correctly identified participants' errors dropped below 80% for group sizes larger than six.

CONCLUSION

This randomized controlled simulation trial reveals decreased ability of instructors to detect Basic Life Support performance errors with increased group size. The maximum group size enabling Basic Life Support instructors to correct more than 80% of errors is six. We therefore recommend a maximum instructor-to-participant ratio of 1:6 for cardiopulmonary resuscitation courses.

ASSESSMENT OF THE QUALITY OF PEDIATRIC CARDIOPULMONARY RESUSCITATION USING THE IN SITU MOCK CODE TOOL

Objective:

To evaluate the quality of individual and team care for cardiac arrest in a pediatric hospital using clinical surprise simulation (in situ mock code).

Methods:

We conducted an observational study with a sample of the hospital staff. Clinical simulations of cardiorespiratory arrest were performed in several sectors and work shifts. The mock code occurred in vacant beds of the sector without previous notification to the teams on call. One researcher conducted all mock codes and another evaluated individual and team attendance through a questionnaire contemplating recommendation for adequate cardiopulmonary resuscitation, based on the Pediatric Advanced Life Support (PALS) guidelines. At the end of the simulations, the research team provided a debriefing to the team tested.

Results:

Fifteen in situ mock code were performed with 56 nursing professionals (including nurses, nursing residents and technicians) and 11 physicians (including two pediatric residents and four residents of pediatric subspecialties). The evaluation showed that 46.7% of the professionals identified cardiac arrest checking for responsiveness (26.7%) and pulse (46.7%); 91.6% requested cardiac monitoring and venous access. In one case (8.3%) the cardiac compression technique was correct in depth and frequency, while 50% performed cardiopulmonary resuscitation correctly regarding the proportion of compressions and ventilation. According to PALS guidelines, the teams had a good performance in the work dynamics.

Conclusions:

There was low adherence to the PALS guidelines during cardiac arrest simulations. The quality of cardiopulmonary resuscitation should be improved in many points. We suggest periodical clinical simulations in pediatric services to improve cardiopulmonary resuscitation performance.

Evaluation of TEAM dynamics before and after remote simulation training utilizing CERTAIN platform

OBJECTIVE

The current study examines the feasibility and potential effects of long distance, remote simulation training on team dynamics.

DESIGN

The study design was a prospective study evaluating team dynamics before and after remote simulation.

SUBJECTS

Study subjects consisted of interdisciplinary teams (attending physicians, physicians in training, advanced care practitioners, and/or nurses).

SETTING

The study was conducted at nine training sites in eight countries.

INTERVENTIONS

Study subjects completed 2-3 simulation scenarios of acute crises before and after training with the Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN).

MEASUREMENTS AND MAIN RESULTS

Pre- and post-CERTAIN training simulations were evaluated by two independent reviewers utilizing the Team Emergency Assessment Measure (TEAM), which is a 11-item questionnaire that has been validated for assessing teamwork in the intensive care unit. Any discrepancies of greater than 1 point between the two reviewers on any question on the TEAM assessment were sent to a third reviewer to judge. The score that was deemed discordant by the third judge was eliminated. Pre- and post-CERTAIN training TEAM scores were averaged and compared. Of the nine teams evaluated, six teams demonstrated an overall improvement in global team performance following CERTAIN virtual training. For each of the 11 TEAM assessments, a trend toward improvement following CERTAIN training was noted; however, no assessment had universal improvement. 'Team composure and control' had the least absolute score improvement following CERTAIN training. The greatest improvement in the TEAM assessment scores was in the 'team's ability to complete tasks in a timely manner' and in the 'team leader's communication to the team'.

CONCLUSION

The assessment of team dynamics using long distance, virtual simulation training appears to be feasible and may result in improved team performance during simulated patient crises; however, language and video quality were the two largest barriers noted during the review process.

New Era of CPR: Application of I-Technology in Resuscitation

Introduction

The present study evaluated the performance and acceptance of a cardiopulmonary resuscitation (CPR) feedback application for the iPhone (“PocketCPR®”) designed to improve chest compression performance.

Methods

We randomly assigned participants into two groups to perform chest compression with (study group) or without (control group) using the “PocketCPR®” on a manikin. The participants performed totally four sets of chest compression simulating two CPR scenarios. In the first scenario, no advanced airway was inserted while in the second scenario, advanced airway was inserted. We measured and compared the rate and depth of chest compression between the groups in both scenarios. Participants in study group also finished a questionnaire on the use of feedback application.

Results

The mean compression depth of the study group was significantly deeper both in the first scenario (5.22 cm; 4.56 cm, p=0.002; 5.30 cm; 4.56 cm, p=0.001) and the second scenario (5.34 cm; 4.56 cm, p<0.001; 5.35 cm; 4.49 cm, p<0.001). However, the mean compression rate of study group was significantly slower than the control group both in the first scenario (105.19; 118.58, p<0.001; 105.23; 119.36, p<0.001) and the second scenario (106.10; 121.08, p<0.001, 106.61; 117.42, p=0.002).

Conclusion

A mobile phone feedback application “PocketCPR®” improves chest compression quality by increasing the compression depth in laboratory setting. Further study is indicated to demonstrate its benefit in clinical setting.

Evaluation of the Effect of a Clinical Pathway on the Quality of Simulated Pre-Hospital Cardiopulmonary Resuscitation: Primary Experience from a Chinese Pre-Hospital Care Centre

Objective

The aim of this study was to assess the quality of simulated cardiopulmonary resuscitation (CPR) in local pre-hospital care teams and the improvement achieved by using clinical pathways.

Methods

A prospective observation study. The 2010 American Heart Association Guidelines for CPR, the personnel characteristics of ambulance staff, China's legal system requirements, and the available medical resources were used to design a clinical pathway for pre-hospital care of cardiac arrest. Case simulations were used to evaluate the quality of CPR before and after implementation of the clinical pathway.

Results

The number of teams which successfully implemented electrocardiogram monitoring, endotracheal intubation and intravenous access before training were 8 (17.8%), 5 (11.1%) and 6 (13.3%) respectively. These increased to 45 (100%), 43 (95.6%) and 43 (95.6%), respectively, after training. The number of teams with successful implementation of artificial ventilation, airway management and insertion of oropharyngeal airway before training were 43 (95.6%), 38 (84.4%) and 12 (26.7%) respectively. These increased to 45 (100%), 42 (93.3%) and 43 (95.6%), respectively, after training. Nine (20%) teams decided CPR onsite before training and 35 (77.8%) after training. The average rate of chest compressions before and after training was 120.3 ± 17.9 and 123.2 ± 17.1 compressions per minute, respectively (p>0.05).

Conclusion

Training using established clinical pathway significantly improves the quality of CPR and increases the use of ALS techniques. CPR training requires ongoing validation and optimisation to maintain effectiveness. (Hong Kong j.emerg.med. 2015;22:14-22)

A Randomised, Cross over Study Using a Mannequin Model to Evaluate the Effects on CPR Quality of Real-Time Audio-Visual Feedback Provided by a Smartphone Application

Objective

To evaluate the effect of real time feedback provided by smartphone application on cardiopulmonary resuscitation (CPR) performance.

Methods

Participants were randomised in two groups based on whether chest compression with or without the assistance of the smartphone application. Both groups performed hands-only CPR on a mannequin for 4 minutes. Data on CPR performance of both groups was compared. To assess the reliability the feedback value, we compared the CPR data from Skillmeter and data from smartphone. A questionnaire survey to participants about the usefulness of the application was also evaluated.

Results

Twenty-one subjects were recruited for the study. We found no significant difference in mean chest compression rate (103.3±5.0/min vs. 107.1±1.7/min; p=0.133) and depth between the two groups (47.3 [39.3, 56.2] mm vs. 45.8 [40.3, 49.9] mm; p=0.085). The proportion of adequate compression depth over the total compression was significantly higher in the group using the smartphone (38.1% vs. 22.2%; p=0.034). The CPR data displayed on smartphone application in mannequin's chest was not different from Skillmeter software. The majority of the participants considered the application easy to use, but holding the smartphone during CPR hampered compression.

Conclusions

Real-time audio-visual feedback on CPR depth and rate using a smartphone application can help to maintain the adequate chest compression depth in prolonged CPR. A better method to hold the smartphone may maximise the feedback effect on CPR quality. (Hong Kong j.emerg.med. 2014;21:153-160)

Assessment of Iranian Nurses and Emergency Medical Personnel in Terms of Cardiopulmonary Resuscitation Knowledge Based on the 2010 Guideline

Background:

The aim of this study was to compare the cardiopulmonary resuscitation (CPR) knowledge of hospital nurses and emergency medical personnel in Kermanshah, Iran.

Materials and Methods:

This descriptive cross-sectional study was conducted on 330 hospital nurses and 159 emergency medical personnel working in educational hospitals and emergency medical centers in Kermanshah. Data were collected using a validated and reliable (r = 0.74) researcher-made questionnaire consisting of a demographic characteristics questionnaire and the 2010 CPR knowledge questionnaire.

Results:

Based on the most recent CPR guidelines, the knowledge of 19.5%, 78.6%, and 1.9% of the emergency medical staff was excellent, good, and moderate, respectively. None of the participants had poor knowledge. In addition, the knowledge of 20.2%, 65.4%, 14%, and 0.4% of the nurses in this study was excellent, good, moderate, and poor, respectively. There was no significant difference in CPR knowledge between hospital nurses and emergency medical staff. Moreover, no significant association was found between CPR knowledge and gender, age, work experience, field of study, previous occupation, and advanced resuscitation courses. However, CPR knowledge of individuals with training in basic CPR courses was higher than participants without training in these courses (P < 0.05).

Conclusions:

Based on the findings of this study, CPR knowledge among Iranian nurses and emergency medical personnel was in an acceptable range. Nevertheless, it is strongly recommended that nurses and emergency staff receive training according to the most recent CPR guidelines.

The impact of quantitative feedback on the performance of chest compression by basic life support trained clinical staff

BACKGROUND

The quality of CPR is directly related to survival outcomes following sudden cardiac arrest but, CPR competency amongst nursing and medical staff is generally poor. The skills honed in CPR recertification training rapidly decline in quality, even as soon as eight weeks following the training. High frequency low dose training has been recommended to address this decay in skills. Automated training devices that provide feedback may be useful in conducting low dose training, which would assist hospitals to manage the often logistically difficult, and financially costly exercise of conducting training programs. Little evidence is published about the improvement in skills performance that can be derived from isolated feedback from these training devices.

OBJECTIVES

To investigate whether the feedback from an automated training device can produce performance in a 'low dose' episode of re-training on chest compressions and compression depth for CPR.

METHODS

A repeated measures study was conducted assessing the compression rate and depth quality over 2min using a Laerdal QCPR® simulation manikin capable of recording performance data. On-screen feedback was provided to participants between attempts. Convenience sampling recruited undergraduate and qualified nursing and medical staff who were engaged in a CPR recertification program at a major Australian private hospital.

RESULTS

In total, 150 participants were enrolled. Feedback from the automated training device was sufficient to produce a significant improvement in both chest compression rate (95% CI 13.3 to 19.7; p<0.001) and depth (95% CI 5.9 to 9.7; p<0.001) during the low dose training episode.

CONCLUSIONS

The feedback provided from an automated training device was sufficient to produce an improvement in performance in chest compressions in CPR. This demonstrates an alternate staff training model that could improve patient outcomes, and allow for higher frequency training whilst potentially reducing costs and the logistical problems many medical institutions face with staff training.

Community-based automated external defibrillator only resuscitation for out-of-hospital cardiac arrest patients

BACKGROUND

Speed is the cornerstone of rescue for out-of-hospital cardiac arrest. As a consequence, community participation programs have been initiated to decrease response times. Even in the very best of these programs, however, short-term survival rates hover around 10% and long-term survival rates are half that. In most locales, survival is far worse. In Piacenza, Italy, responders have been trained for more than a decade to use publicly available automated external defibrillators (AEDs) and eschew the performance of cardiopulmonary resuscitation (CPR). It is known locally as "Progetto Vita."

METHODS

From 2001 to 2014, we prospectively collected outcome data on all Progetto Vita-treated patients and all 3271 standard emergency medical services (EMS) patients. Progetto Vita rescuers simply accessed a public AED, turned it on, and only followed its instructions. Progetto Vita rescuers did not do CPR of any sort. If EMS arrived prior to initiation or even completion of the Progetto Vita protocol, EMS-supplanted Progetto Vita efforts and patients were not included in the Progetto Vita cohort. Follow-up was collected by each responder's data files, medical record review, and use of the Italian system death index. All cardiac arrest patients' death status was validated in 100% of patients through August 1, 2014.

FINDINGS

Survival to hospital discharge occurred in 39 (41.4%) of the 95 patients treated by Progetto Vita and in 193 (5.9%) of the 3271 EMS patients. At 13-year follow-up, the Kaplan-Meier estimates of survival were 31.8% when AEDs only were used and 2.4% for standard EMS/CPR response. Estimates of survival are significantly better for Progetto Vita AED-only therapy when survival was stratified by time to respond, gender, location of cardiac arrest, and shockable rhythm. Relative to the 95 EMS patients with the fastest response times, Progetto Vita intervention was associated with a more than 2-fold increased rate of survival.

INTERPRETATION

This is the first demonstration of excellent long-term survival from out-of-hospital cardiac arrest by promoting speed and ease of lay AED response without CPR.

Accuracy of instructor assessment of chest compression quality during simulated resuscitation

Objectives

The 2010 American Heart Association Guidelines stress the importance of high quality cardiopulmonary resuscitation (CPR) as a predictor of survival from cardiac arrest. However, resuscitation training is often facilitated and evaluated by instructors without access to objective measures of CPR quality. This study aims to determine whether instructors experienced in the area of adult resuscitation (emergency department staff and senior residents) can accurately assess the quality of chest compressions as a component of their global assessment of a simulated resuscitation scenario.

Methods

This is a prospective observational study in which objective chest compression quality data (rate, depth, and fraction) were collected from the simulation manikin and compared to subjective instructor assessment. Data were collected during weekly simulation training sessions for residents, medical students, and nursing students.

Results

We included data from 24 simulated resuscitation scenarios assessed by 1 of 15 instructors. Subjective assessment of chest compression quality identified an adequate compression rate (100–120 compressions per minute) with a sensitivity of 0.17 (confidence interval [CI] 0.02–0.32) and specificity of 0.06 (CI −0.04–0.15), adequate depth (>50 mm) with a sensitivity of 0 and specificity of 0.38 (CI 0.18–0.57), and adequate fraction (>80%) with a sensitivity of 1 and a specificity of 0.25 (CI 0.08–0.42).

Conclusion

Instructor assessment of chest compression rate, depth, and fraction demonstrates poor sensitivity and specificity when compared to the data from the simulation manikin. These results support the use of objective and technologically supported measures of chest compression quality for feedback during resuscitation education using simulators.

Comparison of two training programmes on paramedic-delivered CPR performance

OBJECTIVE

To compare CPR performance in two groups of paramedics who received CPR training from two different CPR training programmes.

METHODS

Conducted in June 2014 at the Hamad Medical Corporation Ambulance Service, the national ambulance service of the State of Qatar, the CPR performances of 149 new paramedic recruits were evaluated after they had received training from either a traditional CPR programme or a tailored CPR programme. Both programmes taught the same content but differed in the way in which this content was delivered to learners. Exclusive to the tailored programme was mandatory precourse work, continuous assessments, a locally developed CPR instructional video and pedagogical activities tailored to the background education and learner style preferences of paramedics. At the end of each respective training programme, a single examiner who was blinded to the type of training paramedics had received, rated them as competent or non-competent on basic life support skills, condition specific skills, specific overall skills and non-technical skills during a simulated out-of-hospital cardiac arrest (OHCA) assessment.

RESULTS

Paramedics who received CPR training with the tailored programme were rated competent 70.9% of the time, compared with paramedics who attended the traditional programme and who achieved this rating 7.9% of the time (p<0.001). Specific improvements were seen in the time required to detect cardiac arrest, chest compression quality, and time to first monitored rhythm and delivered shock.

CONCLUSIONS

In an OHCA scenario, CPR performance rated as competent was significantly higher when training was received using a tailored CPR programme.

An Integrative Review: Instructional Strategies to Improve Nurses’ Retention of Cardiopulmonary Resuscitation Priorities

Recognizing and responding to a cardiac arrest in the hospital setting is a high stress, high anxiety event for all healthcare providers. It requires the performance of several basic, but extremely important cardiopulmonary resuscitation (CPR) skills and response priorities. If not executed correctly and in a timely manner, a bad outcome may result. Poor retention of cardiopulmonary resuscitation skills and priorities is well documented in the literature. An integrative review of the evidence was conducted to answer the question, “Is there a more effective training method to improve nurses’ retention of CPR priorities during an in hospital cardiac arrest as compared to traditional American Heart Association training? “This review evaluated high fidelity and low fidelity simulation training, online or computer-based training and video instruction as potential teaching strategies focusing on CPR priorities. The role of deliberate practice is discussed. The strongest evidence suggests that a teaching plan employing brief, frequent, repetitive or deliberate practice used in collaboration with low fidelity or high fidelity simulation may be a potential strategy to improve nurses’ retention of CPR priorities over time.

Reliability and accuracy of the thoracic impedance signal for measuring cardiopulmonary resuscitation quality metrics

AIM

To determine the accuracy and reliability of the thoracic impedance (TI) signal to assess cardiopulmonary resuscitation (CPR) quality metrics.

METHODS

A dataset of 63 out-of-hospital cardiac arrest episodes containing the compression depth (CD), capnography and TI signals was used. We developed a chest compression (CC) and ventilation detector based on the TI signal. TI shows fluctuations due to CCs and ventilations. A decision algorithm classified the local maxima as CCs or ventilations. Seven CPR quality metrics were computed: mean CC-rate, fraction of minutes with inadequate CC-rate, chest compression fraction, mean ventilation rate, fraction of minutes with hyperventilation, instantaneous CC-rate and instantaneous ventilation rate. The CD and capnography signals were accepted as the gold standard for CC and ventilation detection respectively. The accuracy of the detector was evaluated in terms of sensitivity and positive predictive value (PPV). Distributions for each metric computed from the TI and from the gold standard were calculated and tested for normality using one sample Kolmogorov-Smirnov test. For normal and not normal distributions, two sample t-test and Mann-Whitney U test respectively were applied to test for equal means and medians respectively. Bland-Altman plots were represented for each metric to analyze the level of agreement between values obtained from the TI and gold standard.

RESULTS

The CC/ventilation detector had a median sensitivity/PPV of 97.2%/97.7% for CCs and 92.2%/81.0% for ventilations respectively. Distributions for all the metrics showed equal means or medians, and agreements >95% between metrics and gold standard was achieved for most of the episodes in the test set, except for the instantaneous ventilation rate.

CONCLUSION

With our data, the TI can be reliably used to measure all the CPR quality metrics proposed in this study, except for the instantaneous ventilation rate.

The effectiveness of a 'train the trainer' model of resuscitation education for rural peripheral hospital doctors in Sri Lanka

BACKGROUND

Sri Lankan rural doctors based in isolated peripheral hospitals routinely resuscitate critically ill patients but have difficulty accessing training. We tested a train-the-trainer model that could be utilised in isolated rural hospitals.

METHODS

Eight selected rural hospital non-specialist doctors attended a 2-day instructor course. These "trained trainers" educated their colleagues in advanced cardiac life support at peripheral hospital workshops and we tested their students in resuscitation knowledge and skills pre and post training, and at 6- and 12-weeks. Knowledge was assessed through 30 multiple choice questions (MCQ), and resuscitation skills were assessed by performance in a video recorded simulated scenario of a cardiac arrest using a Resuci Anne Skill Trainer mannequin.

RESULTS/DISCUSSION/CONCLUSION

Fifty seven doctors were trained. Pre and post training assessment was possible in 51 participants, and 6-week and 12-week follow up was possible for 43, and 38 participants respectively. Mean MCQ scores significantly improved over time (p<0.001), and a significant improvement was noted in "average ventilation volume", "compression count", and "compressions with no error", "adequate depth", "average depth", and "compression rate" (p<0.01). The proportion of participants with compression depth ≥40mm increased post intervention (p<0.05) and at 12-week follow up (p<0.05), and proportion of ventilation volumes between 400-1000mls increased post intervention (p<0.001). A significant increase in the proportion of participants who "checked for responsiveness", "opened the airway", "performed a breathing check", who used the "correct compression ratio", and who used an "appropriate facemask technique" was also noted (p<0.001). A train-the-trainer model of resuscitation education was effective in improving resuscitation knowledge and skills in Sri Lankan rural peripheral hospital doctors. Improvement was sustained to 12 weeks for most components of resuscitation knowledge and skills. Further research is needed to identify which components of training are most effective in leading to sustained improvement in resuscitation.

Use of an electronic decision support tool improves management of simulated in-hospital cardiac arrest

INTRODUCTION

Adherence to advanced cardiac life support (ACLS) guidelines during in-hospital cardiac arrest (IHCA) is associated with improved outcomes, but current evidence shows that sub-optimal care is common. Successful execution of such protocols during IHCA requires rapid patient assessment and the performance of a number of ordered, time-sensitive interventions. Accordingly, we sought to determine whether the use of an electronic decision support tool (DST) improves performance during high-fidelity simulations of IHCA.

METHODS

After IRB approval and written informed consent was obtained, 47 senior medical students were enrolled. All participants were ACLS certified and within one month of graduation. Each participant was issued an iPod Touch device with a DST installed that contained all ACLS management algorithms. Participants managed two scenarios of IHCA and were allowed to use the DST in one scenario and prohibited from using it in the other. All participants managed the same scenarios. Simulation sessions were video recorded and graded by trained raters according to previously validated checklists.

RESULTS

Performance of correct protocol steps was significantly greater with the DST than without (84.7% v 73.8%, p<0.001) and participants committed significantly fewer additional errors when using the DST (2.5 errors vs. 3.8 errors, p<0.012).

CONCLUSION

Use of an electronic DST provided a significant improvement in the management of simulated IHCA by senior medical students as measured by adherence to published guidelines.

Evaluation of a 3D serious game for advanced life support retraining

OBJECTIVE

Advanced life support (ALS) knowledge and skills decrease in as little as three months, but only a few ALS providers actually attend retraining courses. We assess the effectiveness of a 3D serious game as a new tool for frequent ALS retraining.

METHODS

We developed a 3D serious game for scenario-based ALS retraining. The serious game, called EMSAVE, was designed to promote self-correction while playing. We organized a retraining course in which 40 ALS providers played two cardiac arrest scenarios with EMSAVE and took a test with 38 multiple-choice questions before and after playing. We administered the same test again 3 months later to evaluate retention. Participants also rated EMSAVE and the overall retraining experience.

RESULTS

After using EMSAVE, the number of correct answers per participant increased by 4.8 (95%CI +3.4, +6.2, p<0.001) and all but one participant improved. After 3 months, despite an expected decrease in ALS knowledge and skills (-1.9 correct answers, 95%CI -0.6, -3.3, p<0.01), there was a significant retention benefit (+2.9 correct answers per participant, 95%CI +1.5, +4.2, p<0.001). Moreover, all but one participant regarded EMSAVE as a valuable tool to refresh ALS knowledge and skills, and 85% of participants were also willing to devote 1h/month to retrain with the serious game.

CONCLUSIONS

A 3D serious game for scenario-based retraining proved effective to retrain in ALS and supported retention of acquired knowledge and skills at 3 months. EMSAVE also positively engaged and motivated participants.

[Concept for allocation of acute stroke patients: evaluation of the quality of diagnosis reached by the emergency medical services of Münster]

BACKGROUND

Acute stroke is a time- and expertise-critical emergency. An immediate and correct diagnosis by emergency medical services (EMS) in the prehospital phase and patient transfer to the nearest adequate hospital with a stroke unit is required for early treatment of acute stroke.

PATIENTS AND METHODS

We evaluated all patients who were admitted by the EMS of Münster to one of the two stroke units in the town between October 2008 and December 2010 with a diagnosis of acute stroke. Furthermore all patients were critically analyzed who were admitted without a diagnosis of acute stroke by the EMS but nonetheless had a stroke and the correct diagnosis was not found until examination in the neurological department.

RESULTS

We analyzed 615 patients who were admitted to the stroke units with the diagnosis of acute stroke. In 561 cases (91%) this diagnosis could be confirmed, but in 54 patients (9%) the diagnosis by the EMS was incorrect. Epileptic seizure was the most frequent false-positive diagnosis in this group of patients (39%; n = 21). Although the acute symptoms were caused by a stroke, the correct diagnosis was not defined by the EMS in 127 patients. This accounted for 18% of all patients admitted to the emergency departments by the EMS where ultimately a stroke was diagnosed. In 24% of these cases (n = 30) the emergency doctor missed the correct diagnosis, which meant 4% of all patients admitted by the EMS, finally diagnosed with an acute stroke. In all other cases in the group with a false-negative diagnosis (76% or 97 patients) an emergency doctor was not involved in the referral by the EMS.

CONCLUSION

Emergency medical services should be involved in the establishment of admission programs for acute stroke patients to provide the fastest means of transportation to a stroke unit. Coma, symptoms of posterior cerebral circulation and epileptic seizures cause difficulties in ensuring an immediate and correct diagnosis. Sending an emergency doctor to the scene increases diagnostic certainty which is essential to initiate early treatment.

Four-stage teaching technique and chest compression performance of medical students compared to conventional technique

AIM

To compare the 2-stage and 4-stage basic life support teaching technique. The second aim was to test if students' self-evaluated knowledge was in accordance with their actual knowledge.

METHODS

A total of 126 first-year students of the Faculty of Medicine in Ljubljana were involved in this parallel study conducted in the academic year 2009/2010. They were divided into ten groups. Five groups were taught the 2-stage model and five the 4-stage model. The students were tested in a scenario immediately after the course. Questionnaires were filled in before and after the course. We assessed the absolute values of the chest compression variables and the proportions of students whose performance was evaluated as correct according to our criteria. The results were analyzed with independent samples t test or Mann-Whitney-U test. Proportions were compared with χ(2) test. The correlation was calculated with the Pearson coefficient.

RESULTS

There was no difference between the 2-stage (2S) and the 4-stage approach (4S) in the compression rate (126±13 min-1 vs 124±16 min -1, P=0.180, independent samples t test), compression depth (43±7 mm vs 44±8 mm, P=0.368, independent samples t test), and the number of compressions with correct hand placement (79±32% vs 78±12, P=0.765, Mann-Whitney U-test). However, students from the 4-stage group had a significantly higher average number of compressions per minute (70±13 min -1 2S, 78±12 min-1 4S, P=0.02, independent samples t test). The percentage of students with all the variables correct was the same (13% 2S, 15% 4S, P=0.741, χ2 test). There was no correlation between the students' actual and self-evaluated knowledge (P=0.158, Pearson coefficient=0.127).

CONCLUSIONS

The 4-stage teaching technique does not significantly improve the quality of chest compressions. The students' self-evaluation of their performance after the course was too high.

Impact of a web based interactive simulation game (PULSE) on nursing students' experience and performance in life support training--a pilot study

The delivery of effective life support measures is highly associated with the quality, design and implementation of the education that underpins it. Effectively responding to a critical event is a requirement for all nurses illustrating the need for effective educational approaches from pre-registration training through to enhancing and maintaining life support skills after qualification. This paper reports the findings of utilising a web-based multimedia simulation game PULSE (Platform for Undergraduate Life Support Education). The platform was developed to enhance the student experience of life support education, to motivate on-going learning and engagement and to improve psychomotor skills associated with the provision of Intermediate Life Support (ILS) training. Pre training participants played PULSE and during life support training data was collected from an intervention and a control group of final year undergraduate nursing students (N=34). Quantitative analysis of performance took place and qualitative data was generated from a questionnaire assessing the learning experience. A statistically significant difference was found between the competence the groups displayed in the three skills sets of checking equipment, airway assessment and the safe/effective use of defibrillator at ILS level, and PULSE was positively evaluated as an educational tool when used alongside traditional life support training.

Annual resuscitation competency assessments: a review of the evidence

BACKGROUND

Australian critical care nurses generally undertake assessment of resuscitation competencies on an annual or biannual basis. International resuscitation evidence and guidelines released in 2010 do not support this practice, instead advocating more frequent retraining.

AIM

To review the evidence for annual assessment of resuscitation knowledge and skills, and for the efficacy of resuscitation training practices.

METHODS

A search of the Medline and CINAHL databases was conducted using the key search words/terms 'resuscitation' 'advanced life support' 'advanced cardiac life support' 'assessment' 'cardiac arrest', 'in-hospital cardiac arrest', 'competence', 'training', 'ALS', 'ACLS' 'course' and 'competency'. The search was limited to English language publications produced during the last 10 years. The International Liaison Committee On Resuscitation worksheets were reviewed for key references, as were the reference lists of articles from the initial search.

RESULTS

There is little evidence to support the current practice of annual resuscitation competency assessments. Theoretical knowledge has no correlation with resuscitation performance, and current practical assessment methods are problematic. Both knowledge and skills decline well before the 12-month mark. There is emerging support in the literature for frequent practice sessions using simulation technology.

CONCLUSION

The current practice of annual assessments is not supported by evidence. Emerging evidence for regular resuscitation practice is not conclusive, but it is likely to produce better outcomes. Changing practice in Australia also represents an opportunity to generate data to inform practice further.

Assessment of CPR interruptions from transthoracic impedance during use of the LUCAS™ mechanical chest compression system

BACKGROUND

Quality of cardiopulmonary resuscitation (CPR) is a key determinant of outcome following out-of-hospital cardiac arrest (OHCA). Recent evidence shows manual chest compressions are typically too shallow, interruptions are frequent and prolonged, and incomplete release between compressions is common. Mechanical chest compression systems have been developed as adjuncts for CPR but interruption of CPR during their use is not well documented.

AIM

Analyze interruptions of CPR during application and use of the LUCAS™ chest compression system.

METHODS

54 LUCAS 1 devices operated on compressed air, deployed in 3 major US emergency medical services systems, were used to treat patients with OHCA. Electrocardiogram and transthoracic impedance data from defibrillator/monitors were analyzed to evaluate timing of CPR. Separately, providers estimated their CPR interruption time during application of LUCAS, for comparison to measured application time.

RESULTS

In the 32 cases analyzed, compressions were paused a median of 32.5s (IQR 25-61) to apply LUCAS. Providers' estimates correlated poorly with measured pause length; pauses were often more than twice as long as estimated. The average device compression rate was 104/min (SD 4) and the average compression fraction (percent of time compressions were occurring) during mechanical CPR was 0.88 (SD 0.09).

CONCLUSIONS

Interruptions in chest compressions to apply LUCAS can be <20s but are often much longer, and users do not perceive pause time accurately. Therefore, we recommend better training on application technique, and implementation of systems using impedance data to give users objective feedback on their mechanical chest compression device use.

A tool for immediate and automated assessment of resuscitation skills for a full-scale simulator

Background

For performance assessment during simulation, mostly observers rate the trainees' performance using checklists. Simulator outcome may provide immediate and objective feedback to the participants but requires additional work for the accurate scenario design. High-fidelity simulators are based on physiologic models and store all changes of the simulator conditions during the scenarios and may therefore be used for the assessment of performance. In the present work, the design of a simulator script for the assessment of resuscitation skills using an Emergency Care Simulator (ECS, METI, Sarasota, Florida) is described.

Findings

A standardized resuscitation simulator script and a visual basic-based macro were programmed for the immediate and automated extraction of performance-related variables from the log files. The following parameters were assessed: mean cardiac output, time until return of spontaneous circulation, no-flow-time, no-flow-time fraction, the time until the first defibrillation, the number and fraction of indicated and non-indicated defibrillations. Furthermore, mean deviation of defibrillation interval from the 2 minutes interval, the mean interval of defibrillations and the time until the first administration of epinephrine were calculated. As an example, the results of resuscitation efforts according to 2005 guidelines by five teams that consisted of one emergency physician and two paramedics are presented. No data are provided about its validity and reliability.

Conclusion

The tool can be used to assess adherence to European and American cardiopulmonary resuscitation guidelines (both 2005 and 2010) and to compare simulator outcome if different guidelines are trained and applied according to specific curricula. It represents an example of how simulator outcome can be used for performance assessment and may help to design more complex test-scenarios including the field of critical incidents in anesthesia.

"Putting it all together" to improve resuscitation quality

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

In-hospital resuscitation evaluated by in situ simulation: a prospective simulation study

Background

Interruption in chest compressions during cardiopulmonary resuscitation can be characterized as no flow ratio (NFR) and the importance of minimizing these pauses in chest compression has been highlighted recently. Further, documentation of resuscitation performance has been reported to be insufficient and there is a lack of identification of important issues where future efforts might be beneficial. By implementing in situ simulation we created a model to evaluate resuscitation performance. The aims of the study were to evaluate the feasibility of the applied method, and to examine differences in the resuscitation performance between the first responders and the cardiac arrest team.

Methods

A prospective observational study of 16 unannounced simulated cardiopulmonary arrest scenarios was conducted. The participants of the study involved all health care personel on duty who responded to a cardiac arrest. We measured NFR and time to detection of initial rhythm on defibrillator and performed a comparison between the first responders and the cardiac arrest team.

Results

Data from 13 out of 16 simulations was used to evaluate the ability of generating resuscitation performance data in simulated cardiac arrest. The defibrillator arrived after median 214 seconds (180-254) and detected initial rhythm after median 311 seconds (283-349). A significant difference in no flow ratio (NFR) was observed between the first responders, median NFR 38% (32-46), and the resuscitation teams, median NFR 25% (19-29), p < 0.001. The difference was significant even after adjusting for pulse and rhythm check and shock delivery.

Conclusion

The main finding of this study was a significant difference between the first responders and the cardiac arrest team with the latter performing more adequate cardiopulmonary resuscitation with regards to NFR. Future research should focus on the educational potential for in-situ simulation in terms of improving skills of hospital staff and patient outcome.

The impact of chest compression rates on quality of chest compressions - a manikin study

PURPOSE

Chest compressions are often performed at a variable rate during cardiopulmonary resuscitation (CPR). The effect of compression rate on other chest compression quality variables (compression depth, duty-cycle, leaning, performance decay over time) is unknown. This randomised controlled cross-over manikin study examined the effect of different compression rates on the other chest compression quality variables.

METHODS

Twenty healthcare professionals performed 2 min of continuous compressions on an instrumented manikin at rates of 80, 100, 120, 140 and 160 min(-1) in a random order. An electronic metronome was used to guide compression rate. Compression data were analysed by repeated measures ANOVA and are presented as mean (SD). Non-parametric data was analysed by Friedman test.

RESULTS

At faster compression rates there were significant improvements in the number of compressions delivered (160(2) at 80 min(-1) vs. 312(13) compressions at 160 min(-1), P<0.001); and compression duty-cycle (43(6)% at 80 min(-1) vs. 50(7)% at 160 min(-1), P<0.001). This was at the cost of a significant reduction in compression depth (39.5(10)mm at 80 min(-1) vs. 34.5(11)mm at 160 min(-1), P<0.001); and earlier decay in compression quality (median decay point 120 s at 80 min(-1) vs. 40s at 160 min(-1), P<0.001). Additionally not all participants achieved the target rate (100% at 80 min(-1) vs. 70% at 160 min(-1)). Rates above 120 min(-1) had the greatest impact on reducing chest compression quality.

CONCLUSIONS

For Guidelines 2005 trained rescuers, a chest compression rate of 100-120 min(-1) for 2 min is feasible whilst maintaining adequate chest compression quality in terms of depth, duty-cycle, leaning, and decay in compression performance. Further studies are needed to assess the impact of the Guidelines 2010 recommendation for deeper and faster chest compressions.

Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest

BACKGROUND

Perishock pauses are pauses in chest compressions before and after defibrillatory shock. We examined the relationship between perishock pauses and survival to hospital discharge.

METHODS AND RESULTS

We included out-of-hospital cardiac arrest patients in the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest who suffered arrest between December 2005 and June 2007, presented with a shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia), and had cardiopulmonary resuscitation process data for at least 1 shock (n=815). We used multivariable logistic regression to determine the association between survival and perishock pauses. In an analysis adjusted for Utstein predictors of survival, the odds of survival were significantly lower for patients with preshock pause ≥20 seconds (odds ratio, 0.47; 95% confidence interval, 0.27 to 0.82) and perishock pause ≥40 seconds (odds ratio, 0.54; 95% confidence interval, 0.31 to 0.97) compared with patients with preshock pause <10 seconds and perishock pause <20 seconds. Postshock pause was not independently associated with a significant change in the odds of survival. Log-linear modeling depicted a decrease in survival to hospital discharge of 18% and 14% for every 5-second increase in both preshock and perishock pause interval (up to 40 and 50 seconds, respectively), with no significant association noted with changes in the postshock pause interval.

CONCLUSIONS

In patients with cardiac arrest presenting in a shockable rhythm, longer perishock and preshock pauses were independently associated with a decrease in survival to hospital discharge. The impact of preshock pause on survival suggests that refinement of automatic defibrillator software and paramedic education to minimize preshock pause delays may have a significant impact on survival.

Poor chest compression quality with mechanical compressions in simulated cardiopulmonary resuscitation: a randomized, cross-over manikin study

INTRODUCTION

Mechanical chest compression devices are being implemented as an aid in cardiopulmonary resuscitation (CPR), despite lack of evidence of improved outcome. This manikin study evaluates the CPR-performance of ambulance crews, who had a mechanical chest compression device implemented in their routine clinical practice 8 months previously. The objectives were to evaluate time to first defibrillation, no-flow time, and estimate the quality of compressions.

METHODS

The performance of 21 ambulance crews (ambulance nurse and emergency medical technician) with the authorization to perform advanced life support was studied in an experimental, randomized cross-over study in a manikin setup. Each crew performed two identical CPR scenarios, with and without the aid of the mechanical compression device LUCAS. A computerized manikin was used for data sampling.

RESULTS

There were no substantial differences in time to first defibrillation or no-flow time until first defibrillation. However, the fraction of adequate compressions in relation to total compressions was remarkably low in LUCAS-CPR (58%) compared to manual CPR (88%) (95% confidence interval for the difference: 13-50%). Only 12 out of the 21 ambulance crews (57%) applied the mandatory stabilization strap on the LUCAS device.

CONCLUSIONS

The use of a mechanical compression aid was not associated with substantial differences in time to first defibrillation or no-flow time in the early phase of CPR. However, constant but poor chest compressions due to failure in recognizing and correcting a malposition of the device may counteract a potential benefit of mechanical chest compressions.

Educational polymorphisms of basic life support algorithms

BACKGROUND

A systematic review of the pooled effect of articles presenting current basic life support (BLS) algorithms for the treatment of cardiac arrest has never been carried.

AIMS

We aimed to record and classify potential inherent factors influencing simplicity negatively in teaching, learning and retention of cardiopulmonary resuscitation (CPR) delivered by health care providers or lay persons.

METHODS

We performed a search of the relevant literature exploring MEDLINE, COCHRANE LIBRARY and SCOPUS databases. Potential inhibitory factors in the structure of available algorithms influencing simplicity in teaching, learning and retention of BLS were recorded and stratified accordingly. In a second phase of this study, we tested the hypothesis that different options of a BLS algorithm might influence CPR retention negatively, by asking 348 health care provider participants of our CPR seminars to describe their predicted response in an emergency to: (1) a real-time model implicating the various victims and rescuers; and (2) a hypothetical challenging 'all-in-one' BLS algorithm model.

RESULTS

Fifteen articles presenting current BLS algorithms evidenced 163 suggestions that produced 23 different CPR options: five contrasting algorithms (21.8%); three two-option models (13%); six vague technical or scientific suggestions (26%); and nine multiple choices of action (39.1%). Identified references contributed differently in the development of educationally polymorphic BLS options in each of the four categories (P < 0.0001) and were all brought about by variants of victims and rescuers. Participants of CPR seminars answered that in an emergency they could remember the hypothetical BLS model (90%, P = 0.007) rather than a current BLS algorithm for adults (42.2%) or children (36%).

CONCLUSIONS

Educational polymorphisms of BLS algorithms could build unpredictable barriers between rescuers and cardiac arrest victims and might seriously limit instructors' educational effectiveness. These findings might support an alternative trial hypothesis of a simple 'all-in-one algorithm' educational approach in future.

A randomised control trial to determine if use of the iResus© application on a smart phone improves the performance of an advanced life support provider in a simulated medical emergency

This study sought to determine whether using the Resuscitation Council UK's iResus© application on a smart phone improves the performance of doctors trained in advanced life support in a simulated emergency. Thirty-one doctors (advanced life support-trained within the previous 48 months) were recruited. All received identical training using the smart phone and the iResus application. The participants were randomly assigned to a control group (no smart phone) and a test group (access to iResus on smart phone). Both groups were tested using a validated extended cardiac arrest simulation test (CASTest) scoring system. The primary outcome measure was the overall cardiac arrest simulation test score; these were significantly higher in the smart phone group (median (IQR [range]) 84.5 (75.5-92.5 [64-96])) compared with the control group (72 (62-87 [52-95]); p=0.02). Use of the iResus application significantly improves the performance of an advanced life support-certified doctor during a simulated medical emergency. Further studies are needed to determine if iResus can improve care in the clinical setting.