The challenge of CPR quality: Improvement in the real world

Retention of Cardiopulmonary Resuscitation Skills in Medical Students

Fundamento

A redução da mortalidade e das sequelas de uma vítima de parada cardíaca depende de um atendimento eficaz, rápido e iniciado o mais precocemente possível. O suporte básico de vida (SBV) compreende uma série de etapas que podem ser iniciadas fora do ambiente hospitalar, e ensinadas para qualquer pessoa em cursos específicos. Porém, é importante que o socorrista retenha o conhecimento e as habilidades, pois nunca se sabe quando será necessário realizar uma ressuscitação cardiopulmonar (RCP). Entretanto, estudos mostram que existe uma perda das habilidades em executar uma RCP já com 30 dias após o treinamento, com variações segundo algumas características das pessoas e da atividade profissional.

Objetivo

Avaliar se os estudantes de medicina são capazes de reter as habilidades por mais de seis meses.

Métodos

Estudo prospectivo, caso controle, observacional. Estudantes de medicina realizaram um curso sobre morte súbita e parada cardíaca de 40 horas. A avaliação das habilidades foi realizada imediatamente após o curso e seis meses depois. Foram comparadas as notas individuais entre dois momentos, foi avaliada a porcentagem de acerto em cada etapa e uma análise global do atendimento foi classificado como ótimo, bom e ruim. Os avaliadores e critérios foram os mesmos nos dois momentos. Os dados foram analisados pelos teste-t pareado e teste de McNemar, onde para um nível de confiança de 95% o critério para significância foi p < 0,05.

Resultados

Cinquenta estudantes (27 do sexo feminino) do primeiro ano, com idade entre 18 e 24 anos (média 21), realizaram o curso. O número de etapas cumpridas de forma correta após seis meses foi significativamente menor que logo após o curso (10,8 vs 12,5 p < 0,001). O sexo e idade não interferiram nos resultados. A qualidade global foi considerada ótima em 78% dos atendimentos realizados logo após o curso, significativamente, maior que os 40% após seis meses (p < 0,01). Após seis meses, maior número de erros foi observado nas etapas relacionadas às habilidades mais práticas (como posicionamento das mãos).

Conclusão

Seis meses após o curso observamos uma perda significativa das habilidades, entre estudantes de medicina, prejudicando a eficácia global do atendimento.

The impact of the patient's initial NACA score on subjective and physiological indicators of workload during pre-hospital emergency care

BACKGROUND

Excessive workload may impair patient safety. However, little is known about emergency care providers' workload during the treatment of life-threatening cases including cardiopulmonary resuscitation (CPR). Therefore, we tested the hypothesis that subjective and physiological indicators of workload are associated with the patient's initial NACA score and that workload is particularly high during CPR.

METHODS

NASA task load index (NASA-tlx) and alarm codes were obtained for 216 sorties of pre-hospital emergency medical care. Furthermore, initial NACA scores of 140 patients were extracted from the physicians' protocols. The physiological workload indicators mean heart rate (HR) and permutation entropy (PeEn) were calculated for 51 sorties of primary care. General linear mixed models were used to analyze the association of NACA scores with subjective (NASA-tlx) and physiological (mean HR, PeEn) measures of workload.

RESULTS

In contrast to the physiological variables PeEn (p = 0.10) and HR (p = 0.19), the mental (p<0.001) and temporal demands (p<0.001) as well as the effort (p<0.001) and frustration (p = 0.04) subscale of the NASA-tlx were significantly associated with initial NACA scores. Compared to NACA = I, an initial NACA score of VI (representing CPR) increased workload by a mean of 389.5% (p = 0.001) in the mental and 345.9% (p<0.001) in the temporal demands, effort by a mean of 446,8% (p = 0.002) and frustration by 190.0% (p = 0.03). In line with the increase in NASA-tlx, PeEn increased by 20.6% (p = 0.01) and HR by 6.4% (p = 0.57).

CONCLUSIONS

Patients' initial NACA scores are associated with subjective workload. Workload was highest during CPR.

Assessment of nurses' cardiopulmonary resuscitation knowledge and skills within three district hospitals in Botswana

BACKGROUND

 Nurses are usually the first to identify the need for and initiate cardiopulmonary resuscitation (CPR) on patients with cardiopulmonary arrest in the hospital setting. Cardiopulmonary resuscitation has been shown to reduce in-hospital deaths when received from adequately trained health care professionals.

AIM

 We aimed to investigate nurses' retention of CPR knowledge and skills at district hospitals in Botswana.

METHODS

 A quantitative, quasi-experimental study was conducted at three hospitals in Botswana. A pre-test, intervention, post-test, and a re-test after 6 months were utilised to determine the retention of CPR knowledge and skills. Non-probability, convenience sampling technique was used to select 154 nurses.The sequences of the test were consistent with the American Heart Association's 2010 basic life support (BLS) guidelines for health care providers. Data were analysed to compare performance over time.

RESULTS

 This study showed markedly deficient CPR knowledge and skills among registered nurses in the three district hospitals. The pre-test knowledge average score (48%) indicated that the nurses did not know the majority of the BLS steps. Only 85 nurses participated in the re-evaluation test at 6 months. While a 26.4% increase was observed in the immediate post-test score compared with the pre-test, the performance of the available participants dropped by 14.5% in the re-test 6 months after the post-test.

CONCLUSION

 Poor CPR knowledge and skills among registered nurses may impede the survival and management of cardiac arrest victims. Employers and nursing professional bodies in Botswana should encourage and monitor regular CPR refresher courses.

Development and Evaluation of a Learning Intervention Targeting First-Year Resident Defibrillation Skills

OBJECTIVES

The aim of the study was to evaluate an educational intervention targeting the acquisition and retention of critical core skills of defibrillation in first-year pediatric residents using simulation-based training and deliberate practice.

METHODS

From January 2011 to April 2012, a total of 23 first-year pediatric residents participated in a pretest-posttest study. An initial survey evaluated previous experience, training, and comfort. The scoring tool was designed and validated using a standard setting procedure and 60% was determined to be the minimum passing score. The 1-hour educational intervention included a brief video describing the defibrillator, 10 to 15 minutes of hands-on time with the defibrillator, and 30 minutes of simulation-based scenarios using deliberate practice with real-time feedback.

RESULTS

The number of subjects who achieved competency in defibrillation skills increased from 8 to 16 of 23 (35% vs 70%, P < 0.05), pretest versus posttest, with the posttest occurring 4 months after the intervention. There was a significant improvement in checklist score (53% vs 68%, P < 0.05) and time to defibrillation (282-189 s, P < 0.05). For those who initiated chest compressions, there was a nonsignificant improvement in time to compressions (50 vs 33 s, P = 0.08). Previous Pediatric Advanced Life Support training was not associated with performance on pretest or posttest.

CONCLUSIONS

This brief educational intervention was shown to be effective 4 months after instruction in achieving and retaining competency of defibrillation skills by first-year pediatric residents. In the process, we uncovered educational gaps in cardiopulmonary resuscitation and other resuscitation skills that need to be addressed in future educational interventions and 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.

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.

Cardiopulmonary resuscitation knowledge and skills of registered nurses in Botswana

BACKGROUND

In Botswana nurses provide most health care in the primary, secondary and tertiary level clinics and hospitals. Trauma and medical emergencies are on the increase, and nurses should have cardiopulmonary resuscitation (CPR) knowledge and skills in order to be able to implement effective interventions in cardiac arrest situations.

OBJECTIVE

The objective of this descriptive study was to assess registered nurses’ CPR knowledge and skills.

METHOD

A pre-test, intervention and re-test time-series research design was adopted, and data were collected from 102 nurses from the 2 referral hospitals in Botswana. A multiple-choice questionnaire and checklist were used to collect data.

RESULTS

All nurses failed the pre-test. Their knowledge and skills improved after training, but deteriorated over the three months until the post-test was conducted.

CONCLUSION

The significantly low levels of registered nurses’ CPR skills in Botswana should be addressed by instituting country-wide CPR training and regular refresher courses

Successful percutaneous coronary intervention during cardiac arrest with use of an automated chest compression device: a case report

Ventricular tachycardia or fibrillation (VT/VF) in patients with ST-elevation myocardial infarction (STEMI) is associated with poor prognosis. Performing manual chest compressions is a serious obstacle for treatment with percutaneous coronary intervention (PCI). Here we introduce a case with refractory VT/VF where the patient was successfully treated with an automated chest compression device, which made revascularization with PCI possible.

Adult out-of-hospital cardiac arrest based on chain of survival in Taoyuan County, northern Taiwan

BACKGROUND

Most out-of-hospital cardiac arrest (OHCA) studies have been conducted in developed countries or metropolitan areas, and few in developing countries or rural areas.

OBJECTIVES

The aims of this study were to determine the weak links in the chain of survival and to estimate the outcomes of OHCA patients in Taoyuan, a nonmetropolitan area in Taiwan.

METHODS

A retrospective review and analysis of OHCA data was conducted. The three outcomes were whether a return of spontaneous circulation (ROSC) was achieved, whether the patient survived to admission, or whether the patient survived to hospital discharge.

RESULTS

From April to December 2008, 1048 OHCA patients were resuscitated, and 712 (67.9%) adult cardiac patients were used in this study. Among these 712 patients, 17.8% achieved ROSC (95% confidence interval [CI] 15.2-20.8%), 16.3% survived to admission (95% CI 13.6-19.0%), and 1.4% survived to discharge (95% CI 0.5-2.3%). Factors significantly associated with the three outcomes were witness status, response time to emergency medical services, and whether the patient had a shockable rhythm. Bystander cardiopulmonary resuscitation (CPR) did not add a notable benefit to the outcomes of OHCA.

CONCLUSIONS

The survival rate of OHCA patients in nonmetropolitan Taiwan was very low (1.4%). Lower witnessed rate, lower bystander CPR rate, and longer response interval in remote areas are the main causes of inferior survival rate.

Effects of socio-emotional stressors on ventilation rate and subjective workload during simulated CPR by lay rescuers

Several studies have documented the occurrence of high ventilation rates during cardiopulmonary resuscitation, but to date, there have been no scientific investigation of the causes of hyperventilation. The objective of the current study was to test the effects of socio-emotional stressors on lay rescuers' ventilation rate in a simulated resuscitation setting using a manikin model. A within-subjects experiment with randomized order of conditions tested lay rescuers' ventilation rate on an intubated manikin during exposure to socio-emotional stressors and during a control condition where no external stressors were present. Ventilation rates and subjective workload were significantly higher during exposure to socio-emotional stressors than during the control condition. All but one of the nine participants ventilated at a higher ventilation rate in the experimental condition. All nine participants rated the subjective workload to be higher during exposure to socio-emotional stressors. Hence, exposure to socio-emotional stressors is associated with increased ventilation rates performed by lay rescuers during simulated cardiac arrest using a manikin model. These findings might have implications for the understanding of the type of situations which hyperventilation may occur. Awareness of these situations may have implications for training of lay rescues.

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.

Cardiac arrest survival did not increase in the Resuscitation Outcomes Consortium after implementation of the 2005 AHA CPR and ECC guidelines

INTRODUCTION

We examined the effect of the 2005 American Heart Association guidelines on survival in the Resuscitation Outcomes Consortium (ROC) Cardiac Arrest Epistry.

METHODS

We surveyed 174 EMS agencies from 8 of 10 ROC sites to determine 2005 AHA guideline implementation, or crossover, date. Two sites with 2005 compatible treatment algorithms prior to guideline release, and agencies that did not adopt the new guidelines during the study period were excluded. Non-traumatic adult cardiac arrests that were not witnessed by EMS, and did not have do not resuscitate orders were included. A linear mixed effects model was applied for survival controlling for time and agency. The "crossover" date was added to the model to determine the effect of the 2005 guidelines.

RESULTS

Of 174 agencies, 85 contributed cases to both cohorts during the 18 month period between 2005/12/01 and 2007/05/31. Of 7779 cases, 5054 occurred during the 13 month (median) interval before crossover and 2725 occurred in the five month (median) interval after crossover. The overall survival rate was 6.1%; 5.8% in the old cohort vs. 6.5%, p=0.23. For VF/VT patients, survival was 14.6% vs. 18.0%, p=0.063. Our model estimated no increase in survival over time (monthly OR 1.014, 95% CI 0.988, 1.041, p=0.28).

CONCLUSION

This study found no significant change in survival rate over time in the early months after implementation. Further longitudinal study is needed to determine the full impact of the guidelines on survival and methods to translate knowledge quickly and effectively in EMS.

The impact of compliant surfaces on in-hospital chest compressions: effects of common mattresses and a backboard

PURPOSE

To evaluate, in a hospital setting, the influence of different, common mattresses, with and without a backboard, on chest movement during CPR.

DESIGN AND SETTING

Sixty CPR sessions (140s each, 30:2, C:R ratio 1:1) were performed using a manikin on standard hospital mattresses, with or without a backboard in combination with variable weights. Sternum-to-spine compression distance was controlled (range 30-60mm) allowing evaluation of the underlying compliant surface on total hand travel.

RESULTS

Movement of the caregiver's hands was significantly larger (up to 111mm at 50mm compression depth, p<0.0001) when sternum-to-spine compressions were performed without a backboard than with one. The extent of this variable extra travel effect depended on the type of mattress as well as the force of compression. Foam mattresses and air chamber systems act as springs and follow hand movement, while 'slow foam' mattresses incorporate time delays, making depth and force sensing harder. A backboard decreases the extra hand movement due to mattress effects by more than 50%, strongly reducing caregiver work.

CONCLUSIONS

Total vertical hand movement is significantly, and clinically relevantly much, larger than sternum-to-spine compression depth when CPR is performed on a mattress. Additional movement depends on the type of mattress and can be strongly reduced, but not eliminated, when a backboard is applied. The additional motion and increased work load adds extra complexity to in-hospital CPR. We propose that this should be taken into account during training by in-hospital caregivers.

The effect of two different counting methods on the quality of CPR on a manikin--a randomized controlled trial

OBJECTIVES

To compare the quality of cardiopulmonary resuscitation (CPR) and rescuers' exhaustion using different methods of counting, and to establish an appropriate method of counting.

MATERIALS AND METHODS

Forty-eight subjects who had received formal training in basic life support (BLS) were recruited from doctors and nurses working in the Emergency Department of a university hospital. They performed 3 min of continuous chest compressions using two different methods of counting, one after the other, on an adult resuscitation manikin. The total number of compressions, the number of these considered satisfactory, the peak heart rate of subjects and the time to peak heart rate were all recorded. Perceived fatigue and discomfort was evaluated by self-reported survey results with use of a visual analogue scale (VAS).

RESULTS

The effective power of external chest compression and the mean compression depth when counting from 1 to 10, repeated three times, were greater than those achieved when counting from 1 to 30 during 3 min of CPR (67.48% vs. 57.81% and 44.52 mm vs. 40.48 mm, P<0.05). The exhaustion-score using the VAS (22.15 points) was lower and the time to peak heart rate (124.88 s) was longer when counting from 1 to 10, repeated three times, than when rescuers counted from 1 to 30.

CONCLUSIONS

Counting from 1 to 10 three times in Chinese as opposed to 1-30 results in better quality chest compressions. Counting from 1 to 10 three times was associated with less user feelings of fatigue, and a longer time to peak heart rate. These findings support the teaching of counting compressions 1-10 three times during CPR.