Part 1: Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Flipped Classroom: Improved team performance during resuscitation training through interactive pre-course content - a cluster-randomised controlled study

BACKGROUND

Resuscitation is a team effort, and it is increasingly acknowledged that team cooperation requires training. Staff shortages in many healthcare systems worldwide, as well as recent pandemic restrictions, limit opportunities for collaborative team training. To address this challenge, a learner-centred approach known as flipped learning has been successfully implemented. This model comprises self-directed, asynchronous pre-course learning, followed by knowledge application and skill training during in-class sessions. The existing evidence supports the effectiveness of this approach for the acquisition of cognitive skills, but it is uncertain whether the flipped classroom model is suitable for the acquisition of team skills. The objective of this study was to determine if a flipped classroom approach, with an online workshop prior to an instructor-led course could improve team performance and key resuscitation variables during classroom training.

METHODS

A single-centre, cluster-randomised, rater-blinded study was conducted on 114 final year medical students at a University Hospital in Germany. The study randomly assigned students to either the intervention or control group using a computer script. Each team, regardless of group, performed two advanced life support (ALS) scenarios on a simulator. The two groups differed in the order in which they completed the flipped e-learning curriculum. The intervention group started with the e-learning component, and the control group started with an ALS scenario. Simulators were used for recording and analysing resuscitation performance indicators, while professionals assessed team performance as a primary outcome.

RESULTS

The analysis was conducted on the data of 96 participants in 21 teams, comprising of 11 intervention groups and 10 control groups. The intervention teams achieved higher team performance ratings during the first scenario compared to the control teams (Estimated marginal mean of global rating: 7.5 vs 5.6, p < 0.01; performance score: 4.4 vs 3.8, p < 0.05; global score: 4.4 vs 3.7, p < 0.001). However, these differences were not observed in the second scenario, where both study groups had used the e-learning tool.

CONCLUSION

Flipped classroom approaches using learner-paced e-learning prior to hands-on training can improve team performance.

TRIAL REGISTRATION

German Clinical Trials Register ( https://drks.de/search/de/trial/DRKS00013096 ).

Factors affecting ward nurses' basic life support experiences: An integrative literature review

BACKGROUND

Performing cardiopulmonary resuscitation in non-critical care hospital wards is a stressful event for the registered nurse; stress may negatively affect performance. Delays in initiating basic life support and following current basic life support algorithms have been reported globally.

AIM

The aim of this review was to investigate factors that can affect registered nurses' experiences of performing basic life support.

METHODS

Using the five-step integrative literature review method from Whittemore and Knafl, this review searched articles published between January 2000 and June 2022 for qualitative and quantitative primary studies from the databases CINAHL Complete (EBSCO), Medline (Web of Science), Scopus and PubMed.

RESULTS

Nine studies from eight countries met the inclusion criteria and were appraised here. Five themes relating to factors affecting the performance of basic life support were found during this review: staff interaction issues, confidence concerns, fear of harm and potential litigation, defibrillation concerns and basic life support training issues.

CONCLUSIONS

This review revealed several concerns experienced by registered nurses in performing basic life support and highlights a lack of research. Factors affecting nurses' experiences need to be understood. This will allow education to focus on consideration of human factors, or non-technical skills during basic life support training, as well as technical skills, to improve outcomes for patients experiencing an in-hospital cardiopulmonary arrest.

Fifteen-year secular changes in the care and outcomes of patients with out-of-hospital cardiac arrest in Japan: a nationwide, population-based study

AIMS

Countries have implemented initiatives to improve the outcomes of patients with out-of-hospital cardiac arrest (OHCA). However, secular changes in care and outcomes at the national level have not been extensively investigated. This study aimed to determine 15-year secular changes in the outcomes of such patients in Japan.

METHODS AND RESULTS

Using population-based data of patients with OHCA, covering all populations in Japan (2005-19), patients for whom resuscitation was attempted were identified. The primary outcome was a favourable neurological outcome (Cerebral Performance Category 1 or 2: sufficient cerebral function for independent activities of daily life and work in a sheltered environment). Secular changes in outcomes were determined using a mixed-level multivariate logistic regression analysis. Overall, 1 764 440 patients (42.4% women; median age, 78 years) were examined. The incidence, median age, and proportion of patients who received bystander cardiopulmonary resuscitation (CPR) and dispatcher instructions for resuscitation increased significantly during the study period (P  < 0.001). A significant trend was noted toward improved outcomes over time (P for trend < 0.001); favourable neurological outcome proportions 1 month after arrest increased from 1.7-3.0% (odds ratio, 1.03 per 1-incremental year). A remarkable increase was noted in favourable neurological outcomes in younger patients and patients with initial shockable cardiac rhythm, while improvement varied among prefectures.

CONCLUSION

In Japan, collaborative efforts have yielded commendable achievements in the care and outcomes of patients with OHCA over 15 years through to 2019, while the improvement depended on patient characteristics. Further initiatives are needed to improve OHCA outcomes.

Improved neurologically favorable survival after OHCA is associated with increased pre-hospital advanced airway management at the prefecture level in Japan

Out-of-hospital cardiac arrest (OHCA) has high incidence and mortality. The survival benefit of pre-hospital advanced airway management (AAM) for OHCA remains controversial. In Japan, pre-hospital AAM are performed for OHCA by emergency medical services (EMS), however the relationship between resuscitation outcomes and AAM at the prefecture level has not been evaluated. The purpose of this study was to describe the association between AAM and neurologically favorable survival (cerebral performance category (CPC) ≦2) at prefecture level. This was a retrospective, population-based study of adult OHCA patients (≧ 18) from January 1, 2014 to December 31, 2017 in Japan. We excluded patients with EMS witnessed arrests. We also only included patients that had care provided by an ELST with the ability to provided AAM and excluded cases that involved prehospital care delivered by a physician. We categorized OHCA into four quartiles (four group: G1-G4) based on frequency of pre-hospital AAM approach rate by prefecture, which is the smallest geographical classification unit, and evaluated the relationship between frequency of pre-hospital AAM approach rates and CPC ≦ 2 for each quartile. Multivariable logistic regression was used to assess effectiveness of AAM on neurologically favorable survival. Among 493,577 OHCA cases, 403,707 matched our inclusion criteria. The number of CPC ≦ 2 survivors increased from G1 to G4 (p for trend < 0.001). In the adjusted multivariable regression, higher frequency of pre-hospital AAM approach was associated with CPC ≦ 2 (p < 0.001). High prefecture frequency of pre-hospital AAM approach was associated with neurologically favorable survival (CPC ≦ 2) in OHCA.

Evaluation of initial shockable rhythm as an indicator of short no-flow time in cardiac arrest: a national registry study

BACKGROUND

The duration from collapse to initiation of cardiopulmonary resuscitation (no-flow time) is one of the most important determinants of outcomes after out-of-hospital cardiac arrest (OHCA). Initial shockable cardiac rhythm (ventricular fibrillation or ventricular tachycardia) is reported to be a marker of short no-flow time; however, there is conflicting evidence regarding the impact of initial shockable cardiac rhythm on treatment decisions. We investigated the association between initial shockable cardiac rhythm and the no-flow time and evaluated whether initial shockable cardiac rhythm can be a marker of short no-flow time in patients with OHCA.

METHODS

Patients aged 18 years and older experiencing OHCA between 2010 and 2016 were selected from a nationwide population-based Japanese database. The association between the no-flow time duration and initial shockable cardiac rhythm was evaluated. Diagnostic accuracy was evaluated using the sensitivity, specificity and positive predictive value.

RESULTS

A total of 177 634 patients were eligible for the analysis. The median age was 77 years (58.3%, men). Initial shockable cardiac rhythm was recorded in 11.8% of the patients. No-flow time duration was significantly associated with lower probability of initial shockable cardiac rhythm, with an adjusted OR of 0.97 (95% CI 0.96 to 0.97) per additional minute. The sensitivity, specificity and positive predictive value of initial shockable cardiac rhythm to identify a no-flow time of <5 min were 0.12 (95% CI 0.12 to 0.12), 0.88 (95% CI 0.88 to 0.89) and 0.35 (95% CI 0.34 to 0.35), respectively. The positive predictive values were 0.90, 0.95 and 0.99 with no-flow times of 15, 18 and 28 min, respectively.

CONCLUSIONS

Although there was a significant association between initial shockable cardiac rhythm and no-flow time duration, initial shockable cardiac rhythm was not reliable when solely used as a surrogate of a short no-flow time duration after OHCA.

Nursing Home Versus Community Resuscitation After Cardiac Arrest: Comparative Outcomes and Risk Factors

OBJECTIVE

To investigate the characteristics and outcomes of patients who experienced cardiac arrest in nursing homes compared with those in private residences and determine prognostic factors for survival.

DESIGN

This was a retrospective study that analyzed data from an Utstein-style registry of the Tokyo Fire Department.

SETTING AND PARTICIPANTS

We identified patients aged ≥65 years who experienced cardiac arrest in a nursing home or private residence from the population-based registry of out-of-hospital cardiac arrests in Tokyo, Japan, from 2014 to 2018.

METHODS

Patients were grouped into the nursing home or the private residence groups according to their cardiac arrest location. We compared the characteristics and outcomes between the 2 groups and determined prognostic factors for survival in the nursing home group. The primary outcome was 1-month survival after cardiac arrest.

RESULTS

In total, 37,550 patient records (nursing home group = 6271; private residence group = 31,279) were analyzed. Patients in the nursing home group were significantly older and more often had witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and shock delivery using an automated external defibrillator. The 1-month survival rate was significantly higher in the nursing home group (2.6% vs 1.8%, P < .001). In the best scenario (daytime emergency call, witnessed cardiac arrest, bystander CPR provided), the 1-month survival rate after cardiac arrest in the nursing home group was 8.0% (95% confidence interval 6.4-9.9%), while none survived if they had neither witness nor bystander CPR.

CONCLUSIONS AND IMPLICATIONS

Survival outcome was significantly better in the nursing home group than in the private residence group and was well stratified by 3 prognostic factors: emergency call timing, witnessed status, and bystander CPR provision. Our results suggest that a decision to withhold vigorous treatment solely based on nursing home residential status is not justified, while termination of resuscitation may be determined by considering significant prognostic factors.

Neurological outcomes associated with prehospital advanced airway management in patients with out-of-hospital cardiac arrest due to foreign body airway obstruction

OBJECTIVES

Several studies have examined the association between advanced airway management (AAM) and survival for arrest that is non-shockable, noncardiac in origin, or due to suffocation; however, the efficacy of prehospital AAM compared with no AAM following foreign body removal by emergency medical services (EMS) has not been examined. We aimed to compare neurological outcomes in patients after out-of-hospital cardiac arrest (OHCA) due to foreign body airway obstruction (FBAO) managed with and without AAM after foreign body removal.

METHODS

This retrospective observational cohort study used all emergency transportation data of Japan and the All-Japan Utstein Registry. We included patients with OHCA aged ≥18 years undergoing resuscitation and removal of airway foreign bodies by EMS from January 2015 to December 2017. The exposure of interest was prehospital AAM by EMS after foreign body removal, and the primary outcome was a favorable neurological outcome at hospital discharge (i.e., a cerebral performance category of 1-2).

RESULTS

Overall, 329,098 adults had OHCAs and 23,060 had foreign bodies removed from their airways; 3681 adult patients met our eligibility criteria and were divided as: AAM (2045) and non-AAM (1636) groups. Propensity score matching resulted in 1210 matched pairs with balanced baseline characteristics between the groups. The rate of favorable neurological outcome was significantly lower in the AAM group than in the non-AAM group (OR 0.34, 95% CI 0.19-0.62). However, survival was not significantly different between the two groups (OR 1.08, 95% CI 0.84-1.37).

CONCLUSIONS

We have not demonstrated the benefit of AAM for patients with OHCA due to FBAO. Further study will be required to confirm the efficacy of AAM for those patients.

Early endotracheal intubation improves neurological outcome following witnessed out-of-hospital cardiac arrest in Japan: a population-based observational study

Aim

It is unclear whether endotracheal intubation in the prehospital setting improves outcomes following out-of-hospital cardiac arrest. The purpose of this study was to evaluate the association between endotracheal intubation time (time from patient contact to endotracheal intubation) and favorable neurological outcomes on out-of-hospital cardiac arrest.

Methods

We extracted patients who underwent endotracheal intubation on the scene from a nationwide out-of-hospital cardiac arrest database registered between 2014 and 2017 in Japan. We included 14,969 witnessed and intubated adult out-of-hospital cardiac arrest cases. Patients were divided into Shockable (n = 1,102) and Non-shockable (n = 13,867) cohorts. We first drew the logistic curve due to predicting the association between endotracheal intubation time and favorable neurological outcome defined as Cerebral Performance Category (CPC) 1 or 2. Secondary, multivariable logistic regressions were used to estimate the association between the endotracheal intubation time (1-min unit increase), CPC 1 or 2.

Results

The logistic curve for CPC 1 or 2 showed similar shapes and indicated a decreasing outcome over time. From the results of multivariable logistic regression, in the Shockable cohort, endotracheal intubation time delay was correlated with decreasing favorable outcomes: CPC 1 or 2 (adjusted odds ratio, 0.89; 95% confidence interval, 0.82-0.87). Results were the same for the Non-shockable cohort: CPC 1 or 2 (adjusted odds ratio, 0.94; 95% confidence interval, 0.89-0.99).

Conclusion

Early endotracheal intubation was correlated with favorable neurological outcome. Training for intubation skills and improving protocols are needed for carrying out early endotracheal intubation.

Short-term outcomes in infants with mild neonatal encephalopathy: a retrospective, observational study

BACKGROUND

Neonatal encephalopathy due to acute perinatal asphyxia is a major cause of perinatal brain damage. Moderate to severe neonatal encephalopathy is associated with high mortality and morbidity rates. However, the neurodevelopmental outcomes in neonates with mild neonatal encephalopathy are unclear. The primary aim of this single-center observational study was to assess the short-term outcomes in term neonates with mild neonatal encephalopathy due to perinatal asphyxia. A secondary aim was to identify predictors of poor prognosis by identifying the characteristics of these infants according to their short-term outcomes.

METHODS

We retrospectively investigated all infants with perinatal asphyxia at Tokyo Metropolitan Children's Medical Center from January 2014 to December 2019. An abnormal short-term outcome was defined as any one of the following: seizures or abnormal electroencephalography, abnormal brain magnetic resonance imaging obtained within the first 4 weeks of life, and abnormal neurological examination findings at discharge.

RESULTS

In total, 110 term infants with perinatal asphyxia during the study period were screened and 61 were diagnosed with mild neonatal encephalopathy. Eleven (18 %) of these infants had an abnormal short-term outcome. The median Thompson score at admission was significantly higher in infants with abnormal short-term outcomes than in those with normal short-term outcomes (5 [interquartile range, 4-5.5] vs. 2 [interquartile range, 1-3], p < 0.01). Receiver operating characteristic curve analysis showed that a cutoff value of 4 had high sensitivity and specificity (90.9 and 83.0 %, respectively) for prediction of an abnormal short-term outcome.

CONCLUSIONS

18 % of infants with mild encephalopathy had an abnormal short-term outcome, such as abnormal brain magnetic resonance imaging findings. The Thompson score at admission may be a useful predictor of an abnormal short-term outcome in infants with mild neonatal encephalopathy.

Effectiveness of public-access automated external defibrillators at Tokyo railroad stations

AIM

To investigate the effectiveness of public-access automated external defibrillators (AEDs) at Tokyo railroad stations.

METHODS

We analysed data from a population-based registry of out-of-hospital cardiac arrests in Tokyo, Japan (2014-2018). We identified patients aged ≥18 years who experienced bystander-witnessed cardiac arrest due to ventricular fibrillation of presumed cardiac origin at railroad stations. The primary outcome was survival at 1 month after cardiac arrest with favourable neurological outcomes (cerebral performance category 1-2).

RESULTS

Among 280 eligible patients who had bystander-witnessed cardiac arrest and received defibrillation at railroad stations, 245 patients (87.5%) received defibrillation using public-access AEDs and 35 patients (12.5%) received defibrillation administered by emergency medical services (EMS). Favourable neurological outcomes at 1 month after cardiac arrest were significantly more common in the group that received defibrillation using public-access AEDs (50.2% vs. 8.6%; adjusted odds ratio: 11.2, 95% confidence interval: 1.43-88.4) than in the group that received defibrillation by EMS. Over a 5-year period, favourable neurological outcomes at 1 month after cardiac arrest of 101.9 cases (95% confidence interval: 74.5-129.4) were calculated to be solely attributable to public-access AED use. The incremental cost-effectiveness ratio to gain one favourable neurological outcome obtained from public-access AEDs at railroad stations was lower than that obtained from nationwide deployment (48.5 vs. 2133.4 AED units).

CONCLUSION

Deploying public-access AEDs at Tokyo railroad stations presented significant benefits and cost-effectiveness. Thus, it may be prudent to prioritise metropolitan railroad stations in public-access defibrillation programs.

Outcomes of patients with OHCA of presumed cardiac etiology that did not achieve prehospital restoration of spontaneous circulation: The All-Japan Utstein Registry experience

BACKGROUND

Correct identification of futile prehospital resuscitation for out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transports. Prehospital return of spontaneous circulation (ROSC) is considered by many to be an important predictor of outcome. The purpose of this study was to evaluate OHCA victims without prehospital ROSC characteristics and their outcomes in relation to the universal Termination of Resuscitation (TOR) rule.

METHODS

A retrospective, population-based review of OHCA victims without prehospital ROSC from January 1, 2010 to December 31, 2017 in the All-Japan Utstein Registry. We compared those that met the universal TOR rule and those that did not for the primary outcome: one-month survival with neurologically favorable Cerebral Performance Category (CPC) 1 or 2.

RESULTS

989,929 OHCA cases, 18 years of age or older, were registered in the All-Japan Utstein Registry and 525,801 cases were of presumed cardiac origin and had no prehospital ROSC. Of these, the one-month CPC was 1 or 2 for 3957 cases (0.8%). In the 'no ROSC' group who also met the TOR rule, the number of cases was 433,571 with a one-month survival of 0.9% (3799 cases), and the proportion with a CPC 1or 2 was 0.2% (699 cases).

CONCLUSIONS

Continued resuscitation and transport of cases with no field ROSC who fulfill the TOR rule is futile and could be considered for adoption in Japan.

On-board emergency medical equipment of European airlines

BACKGROUND

Medical emergencies frequently occur in commercial airline flights, but valid data on causes and consequences are rare. Therefore, optimal extent of onboard emergency medical equipment remains largely unknown. Whereas a minimum standard is defined in regulations, additional material is not standardized and may vary significantly between airlines.

METHODS

European airlines operating aircrafts with at least 30 seats were selected and interviewed with a 5-page written questionnaire including 81 items. Besides pre-packed and required emergency medical material, drugs, medical devices, and equipment lists were queried. If no reply was received, airlines were contacted up to three times by email and/or phone. Descriptive analysis was used for data interpretation.

RESULTS

From a total of 305 European airlines, 253 were excluded from analysis (e.g., no passenger transport). 52 airlines were contacted and data of 22 airlines were available for analysis (one airline was excluded due to insufficient data). A first aid kit is available on all airlines. 82% of airlines (18/22) reported to have a "doctor's kit" (DK) or an "Emergency Medical Kit" (EMK) onboard. 86% of airlines (19/22) provide identical equipment in all aircraft of the fleet, and 65% (14/22) airlines provide an automated external defibrillator.

CONCLUSIONS

Whereas minimal required material according to European aviation regulations is provided by all airlines for medical emergencies, there are significant differences in availability of the additional material. The equipment of most airlines is not sufficient for treatment of specific emergencies according to published in-flight medical guidelines (e.g., for CPR or acute myocardial infarction).

Trends in neonatal resuscitation patterns in Queensland, Australia - A 10-year retrospective cohort study

OBJECTIVES

To describe the frequency of neonatal resuscitation interventions implemented for newborn babies in the state of Queensland over a 10-year period and determine if these changes suggest adherence to changes in Australian guidelines.

STUDY DESIGN

A population-based retrospective cohort study utilising the Queensland Perinatal Data Collection dataset. All liveborn babies ≥23 + 0 weeks + days gestation born between 1 July 2007 and 30 June 2017 were included except those for whom resuscitation was not attempted and those babies <25 + 0 weeks for whom it was unsuccessful. Trends in resuscitation were demonstrated using Loess regression.

RESULTS

Of 618,589 eligible newborns,182,260 received any resuscitation manoeuvre (29.5%). The proportion receiving oxygen without assisted ventilation declined from 19.3% in 2007-08 to 5.6% in 2016-17. Upper airway suctioning also decreased. Assisted ventilation increased from 7.9% to 10.0% of all babies with the largest contribution from late preterm and term babies. The rate of endotracheal suctioning for meconium and the rate of narcotic antagonist use also declined. A greater proportion of babies received chest compressions (1.9-3.2 per 1000 babies) and adrenaline (epinephrine). Mortality decreased from 1.9 to 1.5 per 1000 babies in the cohort.

CONCLUSION

Ten-year trends showed reduced use of oxygen or upper airway suctioning without assisted ventilation, reduced intubation to suction meconium, reduced use of narcotic antagonists and greater use of assisted ventilation suggesting appropriate practice change in response to Australian neonatal resuscitation guidelines. The increase in the use of chest compressions and adrenaline was unexpected and the reasons for it are unclear.

Cardiac Mechano-Electric Coupling: Acute Effects of Mechanical Stimulation on Heart Rate and Rhythm

The heart is vital for biological function in almost all chordates, including humans. It beats continually throughout our life, supplying the body with oxygen and nutrients while removing waste products. If it stops, so does life. The heartbeat involves precise coordination of the activity of billions of individual cells, as well as their swift and well-coordinated adaption to changes in physiological demand. Much of the vital control of cardiac function occurs at the level of individual cardiac muscle cells, including acute beat-by-beat feedback from the local mechanical environment to electrical activity (as opposed to longer term changes in gene expression and functional or structural remodeling). This process is known as mechano-electric coupling (MEC). In the current review, we present evidence for, and implications of, MEC in health and disease in human; summarize our understanding of MEC effects gained from whole animal, organ, tissue, and cell studies; identify potential molecular mediators of MEC responses; and demonstrate the power of computational modeling in developing a more comprehensive understanding of ‟what makes the heart tick.ˮ.

Concordance between the 2010 and 2015 Resuscitation Guidelines of International Liaison Committee of Resuscitation Councils (ILCOR) members and the ILCOR Consensus of Science and Treatment Recommendations (CoSTRs)

BACKGROUND

Cardiac arrests are associated with poor outcomes. The International Liaison Committee on Resuscitation (ILCOR) evaluates resuscitation science and produced, until 2015, five-yearly consensus on science and treatment recommendations (CoSTRs), informing global resuscitation guidelines. We aimed to identify similarities/differences in resuscitation guidelines from ILCOR members, noting concurrence over time, and CoSTRs influence on these guidelines.

METHODS

We considered the component elements of paediatric and adult, basic and advanced resuscitation guidelines, published in 2010 and 2015, along with matching ILCOR CoSTRs to examine their influence. We contacted the responsible councils when guidelines were unavailable online.

RESULTS

Complete resuscitation guidelines were found for six of the seven ILCOR council members. The Resuscitation Council of Asia only had adult basic life support (BLS) guidelines in English. Three members used the AHA guidelines. Therefore, five rather than seven sets of resuscitation guidelines were compared to the CoSTRs. Concurrence between CoSTRs recommendations and ILCOR council member's resuscitation guidelines has improved over time. Minor variations were identified in both basic and advanced life support, with most variance in paediatric guidelines, but these narrowed over time.

CONCLUSION

The improved concurrence across the resuscitation guidelines with the CoSTRs suggests that ILCOR members accept and hence incorporate CoSTRs recommendations to inform their own resuscitation guidelines. This is one step towards the development of international universal guidelines for adult and paediatric resuscitation.

Private residence as a location of cardiac arrest may have a deleterious effect on the outcomes of out-of-hospital cardiac arrest in patients with an initial non-shockable cardiac rhythm: A multicentre retrospective cohort study

AIM

We compared the outcomes between patients who experienced out-of-hospital cardiac arrest at private residences and public locations to investigate whether patient and bystander characteristics can explain the poorer outcomes of out-of-hospital cardiac arrests at private residences.

METHODS

Adult patients with intrinsic out-of-hospital cardiac arrest (n = 6,191, age ≥18 years) were selected from a prospectively collected Japanese database (January 2012 and March 2013). Patients were grouped according to arrest location into private-residence or control (e.g., public station or road, workplace, school, and other public locations) groups. The primary outcome was a favourable neurological outcome 1 month after out-of-hospital cardiac arrest.

RESULTS

The arrest location and initial cardiac rhythm had interaction effects on the outcome. After adjusting for patient and bystander characteristics and relative to the control group, a significantly poorer 1-month neurological outcome was observed in the private-residence group if the initial cardiac rhythm was non-shockable (odds ratio: 0.36, 95% confidence interval: 0.24-0.54), while it was not significant if the initial cardiac rhythm was shockable (odds ratio: 1.16, 95% confidence interval: 0.74-1.84).

CONCLUSIONS

Patients with out-of-hospital cardiac arrest at private residences had poorer outcomes than those with out-of-hospital cardiac arrest at public locations, even after adjusting for patient and bystander characteristics, if the initial cardiac rhythm was non-shockable. Our results suggest that poorer patient and bystander characteristics do not completely explain the poorer outcomes of out-of-hospital cardiac arrests; there may be unknown mechanisms through which the location of cardiac arrest affect the outcomes.

Implementation of Basic Life Support training in schools: a randomised controlled trial evaluating self-regulated learning as alternative training concept

Background

The Kids save lives statement recommends annual Basic Life Support (BLS) training for school children but the implementation is challenging. Trainings should be easy to realise and every BLS training should be as effective as possible to prepare learners for lifesaving actions. Preparedness implies skills and positive beliefs in the own capability (high self-efficacy).

Methods

This randomized controlled cluster study investigates, if self-regulated learning promotes self-efficacy and long-term retention of practical BLS skills. Students in the age of 12 years participated in a practical training in BLS and a scenario testing of skills. In the control group the practical training was instructor-led. In the intervention group the students self-regulated their learning processes and feedback was provided by the peer-group. The primary outcome self-efficacy for helping in cardiac arrest after the training and 9 months later was analysed using a multilevel mixed model. Means and pass-rates for BLS skills were secondary outcomes.

Results

Contrary to the assumptions, this study could not measure a higher self-efficacy for helping in cardiac arrest of the students participating in the intervention (n = 307 students) compared to the control group (n = 293 students) after training and at the follow-up (mean difference: 0.11 points, 95% CI: − 0.26 to 0.04, P = 0.135). The odds to pass all items of the BLS exam was not significantly different between the groups (OR 1.11, 95% CI: 0.81 to 1.52, p = 0.533). Self-regulated learning was associated with a higher performance of male students in the BLS exam (mean score: 7.35) compared to females of the intervention (female: 7.05) and compared to males of the control (7.06).

Conclusion

This study could not resolve the question, if self-regulated learning in peer-groups improves self-efficacy for helping in cardiac arrest. Self-regulated learning is an effective alternative to instructor-led training in BLS skills training and may be feasible to realise for lay-persons. For male students self-regulated learning seems to be beneficial to support long-term retention of skills.

Trial registration

ISRCTN17334920, retrospectively registered 07.03.2019.

Current state of knowledge of basic life support in health professionals of the largest city in Pakistan: a cross-sectional study

Background

Basic Life Support (BLS) is the recognition of sudden cardiac arrest and activation of the emergency response system, followed by resuscitation, and rapid defibrillation. According to WHO, Pakistan has one of the highest mortality rates from accidental deaths therefore assessment and comparison of BLS knowledge in health professionals is crucial. We thereby aim to assess and compare the knowledge of BLS in doctors, dentists and nurses.

Methods

A multi-centric cross-sectional survey was conducted in Karachi at different institutions belonging to the private as well as government sector from January to March 2018. We used a structured questionnaire which was adapted from pretested questionnaires that have been used previously in similar studies. Descriptive statistics were analyzed using SPSS v22.0, where adequate knowledge was taken as a score of at least 50%. P < 0.05 was considered as significant. Logistic regression was used to identify the factors affecting the knowledge regarding BLS in health care professionals.

Results

The responders consisted of 140 doctors, nurses and dentists each. Only one individual (dentist) received a full score of 100%. In total, 58.3% of the population had inadequate knowledge. Average scores of doctors, dentists and nurses were 53.5, 43.3 and 38.4% respectively. Doctors, participants with prior training in BLS and those with 6 to 10 years after graduation were found to be a significant predictor of adequate knowledge, on multivariate analysis.

Conclusion

Even though knowledge of BLS in doctors is better than that of dentists and nurses, overall knowledge of health care professionals is extremely poor. Present study highlights the need for a structured training of BLS for health care workers.

Nursing roles for in-hospital cardiac arrest response: higher versus lower performing hospitals

BACKGROUND

Good outcomes for in-hospital cardiac arrest (IHCA) depend on a skilled resuscitation team, prompt initiation of high-quality cardiopulmonary resuscitation and defibrillation, and organisational structures to support IHCA response. We examined the role of nurses in resuscitation, contrasting higher versus lower performing hospitals in IHCA survival.

METHODS

We conducted a descriptive qualitative study at nine hospitals in the American Heart Association's Get With The Guidelines-Resuscitation registry, purposefully sampling hospitals that varied in geography, academic status, and risk-standardised IHCA survival. We conducted 158 semistructured interviews with nurses, physicians, respiratory therapists, pharmacists, quality improvement staff, and administrators. Qualitative thematic text analysis followed by type-building text analysis identified distinct nursing roles in IHCA care and support for roles.

RESULTS

Nurses played three major roles in IHCA response: bedside first responder, resuscitation team member, and clinical or administrative leader. We found distinctions between higher and lower performing hospitals in support for nurses. Higher performing hospitals emphasised training and competency of nurses at all levels; provided organisational flexibility and responsiveness with nursing roles; and empowered nurses to operate at a higher scope of clinical practice (eg, bedside defibrillation). Higher performing hospitals promoted nurses as leaders-administrators supporting nurses in resuscitation care at the institution, resuscitation team leaders during resuscitation and clinical champions for resuscitation care. Lower performing hospitals had more restrictive nurse roles with less emphasis on systematically identifying improvement needs.

CONCLUSION

Hospitals that excelled in IHCA survival emphasised mentoring and empowering front-line nurses and ensured clinical competency and adequate nursing training for IHCA care. Though not proof of causation, nurses appear to be critical to effective IHCA response, and how to support their role to optimise outcomes warrants further investigation.

Comparing Four Video Laryngoscopes and One Optical Laryngoscope with a Standard Macintosh Blade in a Simulated Trapped Car Accident Victim

Background

Tracheal intubation still represents the “gold standard” in securing the airway of unconscious patients in the prehospital setting. Especially in cases of restricted access to the patient, video laryngoscopy became more and more relevant.

Objectives

The aim of the study was to evaluate the performance and intubation success of four different video laryngoscopes, one optical laryngoscope, and a Macintosh blade while intubating from two different positions in a mannequin trial with difficult access to the patient.

Methods

A mannequin with a cervical collar was placed on the driver's seat. Intubation was performed with six different laryngoscopes either through the driver's window or from the backseat. Success, C/L score, time to best view (TTBV), time to intubation (TTI), and number of attempts were measured. All participants were asked to rate their favored device.

Results

Forty-two physicians participated. 100% of all intubations performed from the backseat were successful. Intubation success through the driver's window was less successful. Only with the Airtraq® optical laryngoscope, 100% success was achieved. Best visualization (window C/L 2a; backseat C/L 2a) and shortest TTBV (window 4.7 s; backseat 4.1 s) were obtained when using the D-Blade video laryngoscope, but this was not associated with a higher success through the driver's window. Fastest TTI was achieved through the window (14.2 s) when using the C-MAC video laryngoscope and from the backseat (7.3 s) when using a Macintosh blade.

Conclusions

Video laryngoscopy revealed better results in visualization but was not associated with a higher success. Success depended on the approach and familiarity with the device. We believe that video laryngoscopy is suitable for securing airways in trapped accident victims. The decision for an optimal device is complicated and should be based upon experience and regular training with the device.

Three-Month Retention of Basic Life Support with an Automated External Defibrillator Using a Two-Stage versus Four-Stage Teaching Technique

Introduction

Resuscitation training increases bystander's ability to perform basic life support (BLS) with an automated external defibrillator (AED) immediately after training. However, several studies indicate that resuscitation skills decay rapidly.

Methods

This study evaluates retention of BLS/AED skills three months after an initial study comparing acquisition of BLS/AED skills among laypersons immediately after training with a two-stage versus four-stage teaching technique.

Results

There was no difference in retention of BLS/AED skills (pass rate 10.8% versus 10.9%, respectively, p=1) three months after training. Total average number of skills adequately performed (of 17) was 13.3 versus 13.7 among laypersons trained with a two-stage and a four-stage technique, respectively. No difference was found in quality of chest compressions and rescue breaths between the two groups.

Conclusion

Three months after training, this study found no difference in retention of BLS/AED skills among laypersons taught using a two-stage compared to a four-stage teaching technique.

Value of EEG reactivity for prediction of neurologic outcome after cardiac arrest: Insights from the Parisian registry

PURPOSE

To evaluate the predictive value of EEG reactivity assessment and confounders for neurological outcome after cardiac arrest.

METHODS

All consecutive patients admitted in a tertiary cardiac arrest center between 2007 and 2016 still alive 48 h after admission with at least one EEG recorded during coma. EEG reactivity was defined as a reproducible waveform change in amplitude or frequency following standardized stimulation. Each EEG was classified based on American Clinical Neurophysiology Society nomenclatures and classified in highly malignant (including status epilepticus), malignant, or benign EEG. We assessed the predictive values of EEG reactivity and sedation effect for neurologic outcome at ICU discharge using the Cerebral Performance Category scale (with CPC 1-2 assumed as favorable outcome and CPC 3-4-5 considered as poor outcome).

RESULTS

Among 428 patients, a poor outcome was observed in 80% patients. The median time to EEG recording was 3 (1-4) days and 51% patients had a non-reactive EEG. The positive predictive value (PPV) of a non-reactive EEG to predict an unfavorable outcome was 97.1% (IC95% 93.6-98.9), increasing to 98.3% (IC95 94.1-99.8) when the EEG had been performed without sedation. In multivariate analysis, a non-reactive EEG was associated with poor outcome (OR 12.6 IC95% 4.7-33.6; p < 0.001). In multivariate analysis, concomitant sedation was not statistically associated with EEG non-reactivity. The PPV of a benign EEG to predict favorable outcome was 49.7% (IC95% 41.5-57.9), increasing to 66.2% (IC95% 54.3-76.8) when EEG was recorded earlier, with ongoing sedation.

CONCLUSIONS

After cardiac arrest, absence of EEG reactivity was predictive of unfavorable outcome. By contrast, a benign EEG was slightly predictive of a favorable outcome. Reactivity assessment may have important implications in the neuroprognostication process after cardiac arrest and could be influenced by sedation.

Diagnostic and prognostic utility of cardiac troponin in post-cardiac arrest care

BACKGROUND

Cardiac troponin is routinely tested in the post-cardiac arrest setting, but its utility in identifying ischaemic aetiology and predicting left ventricular systolic dysfunction (LVSD) and survival is not known.

METHODS

In a retrospective single center registry, we identified 145 consecutive patients who had achieved return of spontaneous circulation after cardiac arrest and had undergone serial cardiac troponin T (cTnT) testing, echocardiogram, and expert adjudication of aetiology. Initial and peak cTnT were evaluated for assessing ischaemic aetiology, LVSD, and survival to discharge using area under the receiver operating characteristic curve (AUROC).

RESULTS

Mean age was 61 ± 14 years and 71% were men. Of the 145 arrests, 19% had an ischaemic aetiology, 68% had LVSD post-arrest, and 55% survived to discharge. All patients had a positive initial cTnT at 0.01 ng/mL (clinical cut-off). Even at higher cut-offs of 10×, 100× and 1000×, initial cTnT performed poorly (AUROC 0.57, 0.56, and 0.56) and peak cTnT performed modestly (AUROC 0.55, 0.61, and 0.62) as diagnostic tests for ischaemic aetiology. Similarly, even at higher cut-offs, initial (AUROC 0.60, 0.62, 0.55) and peak (AUROC 0.57, 0.61, and 0.62) cTnT performed poorly to modestly at predicting LVSD. The test performed poorly for predicting survival to discharge (AUROC for all <0.6).

CONCLUSIONS

At both current and several-fold higher thresholds, cTnT does not perform sufficiently well to guide clinical decision-making or predict patient outcomes. Routine post-cardiac arrest testing of cTnT should be reevaluated.

Effect of Trans-Nasal Evaporative Intra-arrest Cooling on Functional Neurologic Outcome in Out-of-Hospital Cardiac Arrest: The PRINCESS Randomized Clinical Trial

IMPORTANCE

Therapeutic hypothermia may increase survival with good neurologic outcome after cardiac arrest. Trans-nasal evaporative cooling is a method used to induce cooling, primarily of the brain, during cardiopulmonary resuscitation (ie, intra-arrest).

OBJECTIVE

To determine whether prehospital trans-nasal evaporative intra-arrest cooling improves survival with good neurologic outcome compared with cooling initiated after hospital arrival.

DESIGN, SETTING, AND PARTICIPANTS

The PRINCESS trial was an investigator-initiated, randomized, clinical, international multicenter study with blinded assessment of the outcome, performed by emergency medical services in 7 European countries from July 2010 to January 2018, with final follow-up on April 29, 2018. In total, 677 patients with bystander-witnessed out-of-hospital cardiac arrest were enrolled.

INTERVENTIONS

Patients were randomly assigned to receive trans-nasal evaporative intra-arrest cooling (n = 343) or standard care (n = 334). Patients admitted to the hospital in both groups received systemic therapeutic hypothermia at 32°C to 34°C for 24 hours.

MAIN OUTCOMES AND MEASURES

The primary outcome was survival with good neurologic outcome, defined as Cerebral Performance Category (CPC) 1-2, at 90 days. Secondary outcomes were survival at 90 days and time to reach core body temperature less than 34°C.

RESULTS

Among the 677 randomized patients (median age, 65 years; 172 [25%] women), 671 completed the trial. Median time to core temperature less than 34°C was 105 minutes in the intervention group vs 182 minutes in the control group (P < .001). The number of patients with CPC 1-2 at 90 days was 56 of 337 (16.6%) in the intervention cooling group vs 45 of 334 (13.5%) in the control group (difference, 3.1% [95% CI, -2.3% to 8.5%]; relative risk [RR], 1.23 [95% CI, 0.86-1.72]; P = .25). In the intervention group, 60 of 337 patients (17.8%) were alive at 90 days vs 52 of 334 (15.6%) in the control group (difference, 2.2% [95% CI, -3.4% to 7.9%]; RR, 1.14 [95% CI, 0.81-1.57]; P = .44). Minor nosebleed was the most common device-related adverse event, reported in 45 of 337 patients (13%) in the intervention group. The adverse event rate within 7 days was similar between groups.

CONCLUSIONS AND RELEVANCE

Among patients with out-of-hospital cardiac arrest, trans-nasal evaporative intra-arrest cooling compared with usual care did not result in a statistically significant improvement in survival with good neurologic outcome at 90 days.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01400373.

Pre-hospital advanced airway management for adults with out-of-hospital cardiac arrest: nationwide cohort study

OBJECTIVE

To determine survival associated with advanced airway management (AAM) compared with no AAM for adults with out-of-hospital cardiac arrest.

DESIGN

Cohort study between January 2014 and December 2016.

SETTING

Nationwide, population based registry in Japan (All-Japan Utstein Registry).

PARTICIPANTS

Consecutive adult patients with out-of-hospital cardiac arrest, separated into two sub-cohorts by their first documented electrocardiographic rhythm: shockable (ventricular fibrillation or pulseless ventricular tachycardia) and non-shockable (pulseless electrical activity or asystole). Patients who received AAM during cardiopulmonary resuscitation were sequentially matched with patients at risk of AAM within the same minute on the basis of time dependent propensity scores.

MAIN OUTCOME MEASURES

Survival at one month or at hospital discharge within one month.

RESULTS

Of the 310 620 patients eligible, 8459 (41.2%) of 20 516 in the shockable cohort and 121 890 (42.0%) of 290 104 in the non-shockable cohort received AAM during cardiopulmonary resuscitation. After time dependent propensity score sequential matching, 16 114 patients in the shockable cohort and 236 042 in the non-shockable cohort were matched at the same minute. In the shockable cohort, survival did not differ between patients with AAM and those with no AAM: 1546/8057 (19.2%) versus 1500/8057 (18.6%) (adjusted risk ratio 1.00, 95% confidence interval 0.93 to 1.07). In the non-shockable cohort, patients with AAM had better survival than those with no AAM: 2696/118 021 (2.3%) versus 2127/118 021 (1.8%) (adjusted risk ratio 1.27, 1.20 to 1.35).

CONCLUSIONS

In the time dependent propensity score sequential matching for out-of-hospital cardiac arrest in adults, AAM was not associated with survival among patients with shockable rhythm, whereas AAM was associated with better survival among patients with non-shockable rhythm.

Overexpression of programmed cell death-1 and human leucocyte antigen-DR on circulatory regulatory T cells in out-of-hospital cardiac arrest patients in the early period after return of spontaneous circulation

AIM

Whether regulatory T cells (Tregs) are involved in immune disorders of out-of-hospital cardiac arrest (OHCA) patients after return of spontaneous circulation (ROSC) is still unknown. We aimed to observe the expression of circulatory Tregs in OHCA patients and investigate programmed cell death-1 (PD-1) and human leucocyte antigen-DR (HLA-DR) on Tregs to evaluate the induction and activity of Tregs.

METHODS

Sixty-seven consecutive OHCA patients who recovered from spontaneous circulation over 12 h were enrolled. Clinical and 28-day outcome data were collected. Peripheral blood samples collected on days 1 and 3 after ROSC were analysed to evaluate PD-1 and HLA-DR expression on Tregs. Fifty healthy individuals were enrolled as healthy controls.

RESULTS

Compared with those in healthy individuals, circulatory Treg counts significantly decreased without changes of Treg/cluster-of-differentiation (CD)4+ lymphocyte ratios on day 1 after ROSC, and the percentage of PD-1+ Tregs and HLA-DR+ Tregs significantly rose. On day 3, Treg/CD4+ lymphocyte ratios rose with persistently low Treg counts, and the expression of PD-1 and HLA-DR on Tregs was not different from that on day 1. On day 1, both circulatory Treg counts and Treg/CD4+ lymphocyte ratios in non-survivors were lower than those in survivors, and Treg/CD4+ lymphocyte ratios increased in non-survivors on day 3. No significant difference of PD-1 and HLA-DR expression on Tregs was found between survivors and non-survivors on day 1.

CONCLUSIONS

After ROSC, despite decreased circulatory Treg counts, a relative increase of Treg percentage and enhanced activity of Tregs are involved in early immune regulation of OHCA patients.

Epinephrine administration in non-shockable out-of-hospital cardiac arrest

BACKGROUND

Epinephrine is recommended for the treatment of non-shockable out of hospital cardiac arrest (OHCA) to obtain return of spontaneous circulation (ROSC). Epinephrine efficiency and safety remain under debate.

OBJECTIVE

We propose to describe the association between the cumulative dose of epinephrine and the failure of ROSC during the first 30 min of advanced life support (ALS).

METHODOLOGY

A retrospective observational cohort study using the Paris SAMU 75 registry including all non-traumatic OHCA. All OHCA receiving epinephrine during the first 30 min of ALS were enrolled. Cumulative epinephrine dose given during ALS to ROSC was retrieved from medical reports.

RESULTS

Among 1532 patients with OHCA, 776 (51%) had initial non-shockable rhythm. Fifty-four patients were excluded for missing data. The mean value of cumulative dose of epinephrine was 10 ± 4 mg in patients who failed to achieve ROSC (ROSC-) and 4 ± 3 mg (p = 0.04) for those who achieved ROSC. ROC curve analysis indicated a cut-off point of 7 mg total cumulative epinephrine associated with ROSC- (AUC = 0.89 [0.86-0.92]). Using propensity score analysis including age, sex and no-flow duration, association with ROSC- only remained significant for epinephrine > 7 mg (p ≤10-3, OR [CI95] = 1.53 [1.42-1.65]).

CONCLUSION

An association between total cumulative epinephrine dose administered during OHCA resuscitation and ROSC- was reported with a threshold of 7 mg, best identifying patients with refractory OHCA. We suggest using this threshold in this context to guide the termination of ALS and early decide on the implementation of extracorporeal life support or organ harvesting in the first 30 min of ALS.

Sensitivity and specificity of two different automated external defibrillators

AIM

The aim was to investigate the clinical performance of two different types of automated external defibrillators (AEDs).

METHODS

Three investigators reviewed 2938 rhythm analyses performed by AEDs in 240 consecutive patients (median age 72, q1-q3=62-83) who had suffered cardiac arrest between January 2011 and March 2015. Two different AEDs were used (AED A n=105, AED B n=135) in-hospital (n=91) and out-of-hospital (n=149).

RESULTS

Among 194 shockable rhythms, 17 (8.8%) were not recognized by AED A, while AED B recognized 100% (n=135) of shockable episodes (sensitivity 91.2 vs 100%, p<0.01). In AED A, 8 (47.1%) of these episodes were judged to be algorithm errors while 9 (52.9%) were caused by external artifacts. Among 1039 non-shockable rhythms, AED A recommended shock in 11 (1.0%), while AED B recommended shock in 63 (4.1%) of 1523 episodes (specificity 98.9 vs 95.9, p<0.001). In AED A, 2 (18.2%) of these episodes were judged to be algorithm errors (AED B, n=40, 63.5%), while 9 (81.8%) were caused by external artifacts (AED B, n=23, 36.5%).

CONCLUSIONS

There were significant differences in sensitivity and specificity between the two different AEDs. A higher sensitivity of AED B was associated with a lower specificity while a higher specificity of AED A was associated with a lower sensitivity. AED manufacturers should work to improve the algorithms. In addition, AED use should always be reviewed with a routine for giving feedback, and medical personnel should be aware of the specific strengths and shortcomings of the device they are using.

Laryngeal tube suction for airway management during in-hospital emergencies

OBJECTIVE:

The role of supraglottic airway devices in emergency airway management is highlighted in international airway management guidelines. We evaluated the application of the new generation laryngeal tube suction (LTS-II/LTS-D) in the management of in-hospital unexpected difficult airway and cardiopulmonary resuscitation.

METHODS:

During a seven-year period, patients treated with a laryngeal tube who received routine anesthesia and had an unexpected difficult airway (Cormack Lehane Grade 3-4), who underwent cardiopulmonary resuscitation, or who underwent cardiopulmonary resuscitation outside the operating room and had a difficult airway were evaluated. Successful placement of the LTS II/LTS-D, sufficient ventilation, time to placement, number of placement attempts, stomach content, peripheral oxygen saturation/end-tidal carbon dioxide development (SpO2/etCO2) over 5 minutes, subjective overall assessment and complications were recorded.

RESULTS:

In total, 106 adult patients were treated using an LTS-II/LTS-D. The main indication for placement was a difficult airway (75%, n=80), followed by cardiopulmonary resuscitation (25%, n=26) or an overlap between both (18%, n=19). In 94% of patients (n=100), users placed the laryngeal tube during the first attempt. In 93% of patients (n=98), the tube was placed within 30 seconds. A significant increase in SpO2 from 97% (0-100) to 99% (5-100) was observed in the whole population and in cardiopulmonary resuscitation patients. The average initial etCO2 of 39.5 mmHg (0-100 mmHg) decreased significantly to an average of 38.4 mmHg (10-62 mmHg) after 5 minutes. A comparison of cardiopulmonary resuscitation patients with non-cardiopulmonary resuscitation patients regarding gastric contents showed no significant difference.

CONCLUSIONS:

LTS-D/LTS-II use for in-hospital unexpected difficult airway management provides a secure method for primary airway management until other options such as video laryngoscopy or fiber optic intubation become available.

The effect of hormone therapy on quality of life and breast cancer risk after risk-reducing salpingo-oophorectomy: a systematic review

BACKGROUND

It is unclear if the use of hormone therapy (HT) in carriers of BRCA mutations improves the quality of life (QOL) without increasing the risk of breast cancer following a risk-reducing salpingo-oophorectomy (RRSO). Our objective was to assess the effect of HT on QOL and breast cancer risk, after RRSO.

METHODS

We searched MEDLINE, EMBASE, CINHAL, and others, from inception to July 22, 2016, to identify relevant studies. Two reviewers independently screened identified records for controlled trials and observational studies that addressed the effect of HT on QOL and breast cancer risk in women with BRCA mutations, post RRSO. Two reviewers independently extracted data on populations, interventions, comparators, outcomes, and methodological quality. Studies addressing the same outcome were synthesized using written evidence summaries or tables.

RESULTS

Of the 1,059 records identified, 13 met our inclusion criteria. All studies were observational. Six studies assessed the effect on QOL. Of these, 3 showed improvement in QOL with HT use. The risk of breast cancer was evaluated in 4 studies. The mean duration of follow-up was 2.6 years (range 0.1-19.1). The risk of breast cancer did not change with HT use in all 4 studies.

CONCLUSIONS

Cumulative evidence from our review suggests that short-term HT use following RRSO improves QOL. The effect on breast cancer risk is still unclear. There are too few long-term studies to draw any strong conclusions. The need for future well-designed RCTs for more established evidence is imperative.

Lay persons alerted by mobile application system initiate earlier cardio-pulmonary resuscitation: A comparison with SMS-based system notification

AIM

We compared the time to initiation of cardiopulmonary resuscitation (CPR) by lay responders and/or first responders alerted either via Short Message Service (SMS) or by using a mobile application-based alert system (APP).

METHODS

The Ticino Registry of Cardiac Arrest collects all data about out-of-hospital cardiac arrests (OHCAs) occurring in the Canton of Ticino. At the time of a bystander's call, the EMS dispatcher sends one ambulance and alerts the first-responders network made up of police officers or fire brigade equipped with an automatic external defibrillator, the so called "traditional" first responders, and - if the scene was considered safe - lay responders as well. We evaluated the time from call to arrival of traditional first responders and/or lay responders when alerted either via SMS or the new developed mobile APP.

RESULTS

Over the study period 593 OHCAs have occurred. Notification to the first responders network was sent via SMS in 198 cases and via mobile APP in 134 cases. Median time to first responder/lay responder arrival on scene was significantly reduced by the APP-based system (3.5 [2.8-5.2]) compared to the SMS-based system (5.6 [4.2-8.5] min, p 0.0001). The proportion of lay responders arriving first on the scene significantly increased (70% vs. 15%, p<0.01) with the APP. Earlier arrival of a first responder or of a lay responder determined a higher survival rate.

CONCLUSIONS

The mobile APP system is highly efficient in the recruitment of first responders, significantly reducing the time to the initiation of CPR thus increasing survival rates.

So you want to conduct a randomised trial? Learnings from a 'failed' feasibility study of a Crisis Resource Management prompt during simulated paediatric resuscitation

BACKGROUND

No study has tested a Crisis Resource Management prompt on resuscitation performance.

METHODS

We conducted a feasibility, unblinded, parallel-group, randomised controlled trial at one Australian paediatric hospital (June-September 2014). Eligible participants were any doctor, nurse, or nurse manager who would normally be involved in a Medical Emergency Team simulation. The unit of block randomisation was one of six scenarios (3 control:3 intervention) with or without a verbal prompt. The primary outcomes tested the feasibility and utility of the intervention and data collection tools. The secondary outcomes measured resuscitation quality and team performance.

RESULTS

Data were analysed from six resuscitation scenarios (n=49 participants); three control groups (n=25) and three intervention groups (n=24). The ability to measure all data items on the data collection tools was hindered by problems with the recording devices both in the mannequins and the video camera.

CONCLUSIONS

For a pilot study, greater training for the prompt role and pre-briefing participants about assessment of their cardio-pulmonary resuscitation quality should be undertaken. Data could be analysed in real time with independent video analysis to validate findings. Two cameras would strengthen reliability of the methods.

An Interventional Quality Improvement Study to Assess the Compliance to Cardiopulmonary Resuscitation Documentation in an Indian Teaching Hospital

Background

Cardiopulmonary resuscitation (CPR) should be performed as per the international guidelines; however, compliance to these guidelines is difficult to assess. This study was conducted to determine the compliance to American Heart Association (2010) guideline on CPR documentation by among resident physicians before and after resident training (two arms).

Methods

This pre-postinterventional quality improvement study was conducted in a referral center, North India. Data of hospitalized in-hospital CPR patients were collected in the form of quality indicators (checklists) as defined by the guideline and compared between two arms of before-after resident training. Residents were given appropriate training in CPR technique as per the guideline. The compliance of CPR documentation was assessed pre- and post-intervention.

Results

The baseline arm compliance of various components of CPR documentation was low. The postintervention arm compliances of all components significantly increased (baseline, 2.5% to postintervention, 15.11%, P = 0.03). Individual components assessed were documentation of assessment of responsiveness (65% to 77.9%, P = 0.19), assessment of breathing (37.5% to 58.1%, P = 0.03), assessment of carotid pulse (62.5% to 79%, P = 0.05), rate of chest compressions (20% to 39.5%, P = 0.04), airway management (62.5% to 82.5%, P = 0.02), and compressions to breaths ratio (12.5% to 31.4%, P = 0.02). Documentation of chest compression rate compared to nondocumentation (12 of 42 vs. 11 of 84, P = 0.04) was independently associated with a higher rate of return of spontaneous circulation. The study however did not show any survival benefits.

Conclusions

This study establishes that the compliance to CPR documentation is poor as assessed by CPR documentation content and quality, which improves after physician training, but not up to the mark level (100%) that may be due to busy Indian hospital settings and human behavioral factors. Due to ethical constraints of live CPR assessment, this document checklist approach may be considered as an internal quality assessment method for CPR compliance. Furthermore, correct instruction in CPR technique along with proper documentation of the procedure is required, followed up with periodic re-education during the residency period and beyond.

Analyses of inter-rater reliability between professionals, medical students and trained school children as assessors of basic life support skills

BACKGROUND

Training of lay-rescuers is essential to improve survival-rates after cardiac arrest. Multiple campaigns emphasise the importance of basic life support (BLS) training for school children. Trainings require a valid assessment to give feedback to school children and to compare the outcomes of different training formats. Considering these requirements, we developed an assessment of BLS skills using MiniAnne and tested the inter-rater reliability between professionals, medical students and trained school children as assessors.

METHODS

Fifteen professional assessors, 10 medical students and 111-trained school children (peers) assessed 1087 school children at the end of a CPR-training event using the new assessment format. Analyses of inter-rater reliability (intraclass correlation coefficient; ICC) were performed.

RESULTS

Overall inter-rater reliability of the summative assessment was high (ICC = 0.84, 95 %-CI: 0.84 to 0.86, n = 889). The number of comparisons between peer-peer assessors (n = 303), peer-professional assessors (n = 339), and peer-student assessors (n = 191) was adequate to demonstrate high inter-rater reliability between peer- and professional-assessors (ICC: 0.76), peer- and student-assessors (ICC: 0.88) and peer- and other peer-assessors (ICC: 0.91). Systematic variation in rating of specific items was observed for three items between professional- and peer-assessors.

CONCLUSION

Using this assessment and integrating peers and medical students as assessors gives the opportunity to assess hands-on skills of school children with high reliability.

Teaching school children basic life support improves teaching and basic life support skills of medical students: A randomised, controlled trial

BACKGROUND

The "kids save lives" joint-statement highlights the effectiveness of training all school children worldwide in cardiopulmonary resuscitation (CPR) to improve survival after cardiac arrest. The personnel requirement to implement this statement is high. Until now, no randomised controlled trial investigated if medical students benefit from their engagement in the BLS-education of school children regarding their later roles as physicians. The objective of the present study is to evaluate if medical students improve their teaching behaviour and CPR-skills by teaching school children in basic life support.

METHODS

The study is a randomised, single blind, controlled trial carried out with medical students during their final year. In total, 80 participants were allocated alternately to either the intervention or the control group. The intervention group participated in a CPR-instructor-course consisting of a 4h-preparatory seminar and a teaching-session in BLS for school children. The primary endpoints were effectiveness of teaching in an objective teaching examination and pass-rates in a simulated BLS-scenario.

RESULTS

The 28 students who completed the CPR-instructor-course had significantly higher scores for effective teaching in five of eight dimensions and passed the BLS-assessment significantly more often than the 25 students of the control group (Odds Ratio (OR): 10.0; 95%-CI: 1.9-54.0; p=0.007).

CONCLUSIONS

Active teaching of BLS improves teaching behaviour and resuscitation skills of students. Teaching school children in BLS may prepare medical students for their future role as a clinical teacher and support the implementation of the "kids save lives" statement on training all school children worldwide in BLS at the same time.

What change in outcomes after cardiac arrest is necessary to change practice? Results of an international survey

BACKGROUND

Efficient trials of interventions for patients with out-of-hospital cardiac arrest (OHCA) should have adequate but not excess power to detect a difference in outcomes. The minimum clinically important difference (MCID) is the threshold value in outcomes observed in a trial at which providers should choose to adopt a treatment. There has been limited assessment of MCID for outcomes after OHCA. Therefore, we conducted an international survey of individuals interested in cardiac resuscitation to define the MCID for a range of outcomes after OHCA.

METHODS

A brief survey instrument was developed and modified by consensus. Included were open-ended responses. The survey included an illustrative example of a hypothetical randomized study with distributions of outcomes based on those in a public use datafile from a previous trial. Elicited information included the minimum significant difference required in an outcome to change clinical practice. The population of interest was emergency physicians or other practitioners of acute cardiovascular research.

RESULTS

Usable responses were obtained from 160 respondents (50% of surveyed) in 46 countries (79% of surveyed). MCIDs tended to increase as baseline outcomes increased. For a population of patients with 25% survival to discharge and 20% favorable neurologic status at discharge, the MCID were median 5 (interquartile range [IQR] 3, 10) percent for survival to discharge; median 5 (IQR 2, 10) percent for favorable neurologic status at discharge, median 4 (IQR 2, 9) days of ICU-free survival and median 4 (IQR 2, 8) days of hospital-free survival.

CONCLUSION

Reported MCIDs for outcomes after OHCA vary according to the outcome considered as well as the baseline rate of achieving it. MCIDs of ICU-free survival or hospital-free survival may be useful to accelerate the rate of evidence-based change in resuscitation care.

Comparison of Chest Compressions Metrics Measured Using the Laerdal Skill Reporter and Q-CPR: A Simulation Study

INTRODUCTION

There has been an increased emphasis on the quality of chest compressions as a part of the cardiopulmonary resuscitation (CPR) bundle of care for recent times. During CPR training, chest compression quality parameters can be measured directly from sensors within a manikin or from external devices placed on the manikin chest that use accelerometer-based technology. The aim of this study was to compare external chest compression data from the manikin-based Laerdal Skill Reporter (LSR) and the accelerometer-based Q-CPR technology, incorporated into the Philips MRx defibrillator, during CPR on a single Resusci Anne Simulator manikin.

METHODS

Each paramedic (n = 15) performed 2 sessions of 2 minutes of chest compressions, with a 2-minute rest period in between sessions. Both over-the-head and from-the-side positions were used on a single manikin. The quality of chest compressions were concurrently measured using both LSR and Philips MRx Q-CPR accelerometer with audiovisual feedback disabled.

RESULTS

There was no significant difference in the measurement of the number of chest compressions performed in 2 minutes, the compression rate, total number of compressions of adequate depth, or the number of compressions exhibiting leaning between the LSR and the Phillips Q-CPR devices. There was a significant difference in measurement of compression depth (P < 0.0001) and duty cycle (P < 0.0001) with the MRx Q-CPR accelerometer demonstrating both lower compression depth and duty cycle compared with LSR.

CONCLUSIONS

There was no significant difference in most chest compression quality metrics measured between the LSR and the Phillips Q-CPR devices when measured on a manikin. However, there were significant differences in the measurement of duty cycle and also the depth of compressions between the 2 devices with the Phillips Q-CPR device measuring lower depth of compression and duty cycle compared with the LSR device.