Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Effectiveness of a dispatcher-assisted CPR using an animated image: Simulation study

INTRODUCTION

Considering the few studies evaluating bystander cardiopulmonary resuscitation (CPR) performance, we sought to analyze differences in bystander CPR performance with and without the use of our self-developed animated GIFs based on dispatcher-assisted CPR simulation.

METHODS

A total of 80 adults who had not received CPR training over the past two years participated in the study. Among them, 40 people were classified into the auditory group (receiving CPR instructions only over the phone), and the other 40 people were classified into the audiovisual group (receiving CPR instructions over the phone after receiving images on a smartphone). All participants were asked to perform adult and infant CPR for 2 min. CPR performance was recorded using two video cameras (front and side) and analyzed by two emergency physicians, whereas CPR quality was measured using Resusci Anne & Baby QCPR Mk II (Laerdal).

RESULTS

In the adult CPR study, the audiovisual group had higher performance scores for adequacy of "knee position," "hand posture," "elbow extension," and "vertical compression," as well as higher Standard Posture Completeness and Instruction Performance scores (p < 0.001). No significant difference in CPR quality was observed between the two groups. In the infant CPR study, audiovisual group had higher performance scores in adequacy of "compression site," "finger posture," and "vertical compression," as well as higher Standard Posture Completeness and Instruction Performance scores (p < 0.001). Regarding CPR quality, the audiovisual group had higher scores for "adequate compression rate ratio" (p = 0.047).

CONCLUSION

Audiovisual guidance using animated GIFs more effectively improved CPR Standard Posture Completeness and Instruction Performance than did traditional auditory guidance.

Student advanced trauma management and skills (SATMAS): a validation study

INTRODUCTION

Despite trauma accounting 9% of global mortality, it has been demonstrated that undergraduate trauma teaching is inadequate nationally and worldwide. With COVID-19 exacerbating this situation, a scalable, accessible, and cost-effective undergraduate trauma teaching is required.

METHODS

Our Continual Professional Development United Kingdom (CPUDK)-accredited University Hospitals Birmingham (UHB) Major Trauma Service (MTS) affiliated programme consisted of seven biweekly pre-recorded sessions that were delivered online through the Moodle educational platform to University of Birmingham students. Pre- and post-randomised session-specific multiple-choice questions (MCQs) and anonymous feedback forms were administered.

RESULTS

There were 489 student responses, with 63 students completing all seven sessions. On an 8-point scale, students' objective knowledge scores increased by a mean of 1.2 (p < 0.001). Using a 5-point Likert scale, students also showed improvement in subjective outcomes including their confidence in assessing trauma patient (absolute difference (AD) 1.38, p < 0.001), advising initial investigations and formulating initial management plans (AD 1.78, p < 0.001) and thereby their confidence to manage a trauma patient overall (AD 1.98, p < 0.001). A total of 410 student responses endorsed the online delivery of SATMAS through Moodle and recommended SATMAS to future medical students.

CONCLUSION

SATMAS has demonstrated positive student feedback and extensive recruitment from only one centre, demonstrating that our programme can be an indispensable low-cost learning resource that prepares undergraduate medical students for their trauma exams and informs the implementation of clinical skills required by all doctors. We publish our pilot study findings to encourage similar teaching programmes to be adopted at other universities nationally and internationally, to synergistically benefit students, tutors, and ultimately patients, on a larger scale.

Evaluation of video review tools for assessing non-technical skills in emergency department resuscitation teams: a systematic review

BACKGROUND AND IMPORTANCE

Use of video review in medicine is established in contexts such as surgery. Although not widely used in the emergency department (ED), some centres use it to evaluate non-technical skills (NTS) to support teaching and quality improvement.

OBJECTIVE

There is no consensus on assessment of NTS using video review in the ED and the purpose of this review was to identify tools used in this context.

DESIGN, SETTING AND PARTICIPANTS

Studies were identified using Embase, Medline, CINAHL and Google Scholar. Inclusion criterion for the review was NTS of resuscitation teams working within the ED were assessed using video review. A systematic search method was used, and results were synthesised after search criteria was checked by two independent reviewers. Authors settled on the same 9 studies eligible for inclusion.

OUTCOME MEASURES AND ANALYSIS

Reliability and validity of tools identified for use in this context. Due to the heterogeneity of studies, no meta-analysis occurred.

MAIN RESULTS

There are 9 studies included in the review. The review was registered with PROSPERO (Ref No: CRD42022306129). Four unique tools were identified - 6 studies used T-NOTECHS, 1 used TTCA-24, 1 used CALM and 1 used the Communication tool. T-NOTECHS is validated in the literature for use in this context.

CONCLUSION

T-NOTECHS is the tool of choice for assessing ED teams in this context.

Do cardiopulmonary resuscitation real-time audiovisual feedback devices improve patient outcomes? A systematic review and meta-analysis

BACKGROUND

Cardiac arrest is a leading cause of mortality in America and has increased in the incidence of cases over the last several years. Cardiopulmonary resuscitation (CPR) increases survival outcomes in cases of cardiac arrest; however, healthcare workers often do not perform CPR within recommended guidelines. Real-time audiovisual feedback (RTAVF) devices improve the quality of CPR performed. This systematic review and meta-analysis aims to compare the effect of RTAVF-assisted CPR with conventional CPR and to evaluate whether the use of these devices improved outcomes in both in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) patients.

AIM

To identify the effect of RTAVF-assisted CPR on patient outcomes and CPR quality with in- and OHCA.

METHODS

We searched PubMed, SCOPUS, the Cochrane Library, and EMBASE from inception to July 27, 2020, for studies comparing patient outcomes and/or CPR quality metrics between RTAVF-assisted CPR and conventional CPR in cases of IHCA or OHCA. The primary outcomes of interest were return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD), with secondary outcomes of chest compression rate and chest compression depth. The methodological quality of the included studies was assessed using the Newcastle-Ottawa scale and Cochrane Collaboration's "risk of bias" tool. Data was analyzed using R statistical software 4.2.0. results were statistically significant if P < 0.05.

RESULTS

Thirteen studies (n = 17600) were included. Patients were on average 69 ± 17.5 years old, with 7022 (39.8%) female patients. Overall pooled ROSC in patients in this study was 37% (95% confidence interval = 23%-54%). RTAVF-assisted CPR significantly improved ROSC, both overall [risk ratio (RR) 1.17 (1.001-1.362); P = 0.048] and in cases of IHCA [RR 1.36 (1.06-1.80); P = 0.002]. There was no significant improvement in ROSC for OHCA (RR 1.04; 0.91-1.19; P = 0.47). No significant effect was seen in SHD [RR 1.04 (0.91-1.19); P = 0.47] or chest compression rate [standardized mean difference (SMD) -2.1; (-4.6-0.5)]; P = 0.09]. A significant improvement was seen in chest compression depth [SMD 1.6; (0.02-3.1); P = 0.047].

CONCLUSION

RTAVF-assisted CPR increases ROSC in cases of IHCA and chest compression depth but has no significant effect on ROSC in cases of OHCA, SHD, or chest compression rate.

National evaluation of trauma teaching for students (NETTS)

Despite the shift towards consultant-led care, many patients with trauma are still seen by junior doctors. Previous research has demonstrated that junior doctors feel unprepared to work in acute care but there is a paucity of recent research in trauma specifically. Thus, a national study is required to investigate the current state of undergraduate trauma teaching and identify specific areas for improvement. Between August and September 2020, a 35-item structured questionnaire was distributed among doctors who graduated from UK medical schools within the last 4 years. The questionnaire retrospectively assessed their experience of trauma teaching at medical school and their confidence to diagnose and manage patients with trauma. 398 responses were recorded from graduates of 39 UK medical schools. With 79.6% reporting only 0-5 hours of bedside trauma teaching and 51.8% reporting less than 20 hours in Accident and Emergency, graduates reported that trauma teaching was deficient compared with other specialties (78.1%). The majority of graduates were not confident in the initial assessment (72.9%) of a patient with trauma and almost all felt that a short course in trauma would be useful (93.7%). 77.4% of students felt that online learning would be beneficial and 92.9% felt that simulation would be useful. There is lack of standardised undergraduate trauma teaching nationally; a formal undergraduate teaching to ensure that new graduates are competent in the management of trauma would be supported by students. It is likely that a blended learning approach, incorporating e-learning with traditional teaching and clinical experience would be well received.

Anaesthetic National Teaching Programme for Students (ANTPS)

The COVID-19 pandemic has significantly undermined undergraduate anaesthetic teaching in spite of the vital role of the specialty against the pandemic. Anaesthetic National Teaching Programme for Students (ANTPS) was designed to meet the evolving needs of undergraduates and tomorrow's doctor by standardising anaesthetic training, preparing for final exams and equipping competencies vital for doctors of all grades and specialties. Our Royal College of Surgeons England-accredited University-College-Hospital-affiliated programme consisted of six-biweekly sessions were delivered online by anaesthetic trainees. Prerandomised and postrandomised session-specific multiple-choice questions (MCQs) assessed students' improvement in knowledge. Anonymous feedback forms were provided to students after each session and 2 months following the programme. 3743 student feedback forms (92.2% of attendees) across 35 medical-schools were recorded. There was a mean improvement in test score (0.94±1.27, p<0.001). 313 students completed all six sessions. Based on 5-point Likert scale, students who completed the programme showed an improvement in their confidence in knowledge and skills to face common foundation challenges (1.59±1.12, p<0.001) and thus felt better prepared for life as junior doctors (1.60±1.14, p<0.001). With an increase in confidence in students to pass their MCQs, Observed Structured Clinical Examinations and case-based discussion assessments, 3525 students stated they would recommend ANTPS to other students. Unprecedented COVID-19 factors impacting training, positive student feedback and extensive recruitment, demonstrate that our programme is an indispensable learning resource which standardises anaesthetic undergraduate education nationally, prepares undergraduates for their anaesthetic and perioperative exams and lays strong foundations for implementation of clinical skills required by all doctors, to optimise training and patient care.

Quantifying physician's bias to terminate resuscitation. The TERMINATOR Study

Context Deciding on "termination of resuscitation" (TOR) is a dilemma for any physician facing cardiac arrest. Due to the lack of evidence-based criteria and scarcity of the existing guidelines, crucial arbitration to interrupt resuscitation remains at the practitioner's discretion.

AIM

Evaluate with a quantitative method the existence of a physician internal bias to terminate resuscitation.

METHOD

We extracted data concerning OHCAs managed between January 2013 and September 2021 from the RéAC registry. We conducted a statistical analysis using generalized linear mixed models to model the binary TOR decision. Utstein data were used as fixed effect terms and a random effect term to model physicians personal bias towards TOR.

RESULTS

5,144 OHCAs involving 173 physicians were included. The cohort's average age was 69 (SD 18) and was composed of 62% of women. Median no-flow and low-flow times were respectively 6 (IQR [0,12]) and 18 (IQR [10,26]) minutes. Our analysis showed a significant (p<0.001) physician effect on TOR decision. Odds ratio for the "doctor effect" was 2.48 [2.13-2.94] for a doctor one SD above the mean, lower than that of dependency for activities of daily living (41.18 [24.69-65.50]), an age of more than 85 years (38.60 [28.67-51.08]), but higher than that of oncologic, cardiovascular, respiratory disease or no-flow duration between 10 to 20 minutes (1.60 [1.26-2.00]).

CONCLUSIONS

We demonstrate the existence of individual physician biases in their decision about TOR. The impact of this bias is greater than that of a no-flow duration lasting ten to twenty minutes. Our results plead in favor developing tools and guidelines to guide physicians in their decision.

Termination-of-resuscitation rule in the emergency department for patients with refractory out-of-hospital cardiac arrest: a nationwide, population-based observational study

Background

In Japan, emergency medical service (EMS) providers are prohibited from field termination-of-resuscitation (TOR) in out-of-hospital cardiac arrest (OHCA) patients. In 2013, we developed a TOR rule for emergency department physicians (Goto’s TOR rule) immediately after hospital arrival. However, this rule is subject to flaws, and there is a need for revision owing to its relatively low specificity for predicting mortality compared with other TOR rules in the emergency department. Therefore, this study aimed to develop and validate a modified Goto’s TOR rule by considering prehospital EMS cardiopulmonary resuscitation (CPR) duration.

Methods

We analysed the records of 465,657 adult patients with OHCA from the All-Japan Utstein registry from 2016 to 2019 and divided them into two groups: development (n = 231,363) and validation (n = 234,294). The primary outcome measures were specificity, false-positive rate (FPR), and positive predictive value (PPV) of the revised TOR rule in the emergency department for predicting 1-month mortality.

Results

Recursive partitioning analysis for the development group in predicting 1-month mortality revealed that a modified Goto’s TOR rule could be defined if patients with OHCA met the following four criteria: (1) initial asystole, (2) unwitnessed arrest by any laypersons, (3) EMS-CPR duration > 20 min, and (4) no prehospital return of spontaneous circulation (ROSC). The specificity, FPR, and PPV of the rule for predicting 1-month mortality were 99.2% (95% confidence interval [CI], 99.0–99.4%), 0.8% (0.6–1.0%), and 99.8% (99.8–99.9%), respectively. The proportion of patients who fulfilled the rule and the area under the receiver operating curve (AUC) was 27.5% (95% CI 27.3–27.7%) and 0.904 (0.902–0.905), respectively. In the validation group, the specificity, FPR, PPV, proportion of patients who met the rule, and AUC were 99.1% (95% CI 98.9–99.2%), 0.9% (0.8–1.1%), 99.8% (99.8–99.8%), 27.8% (27.6–28.0%), and 0.889 (0.887–0.891), respectively.

Conclusion

The modified Goto’s TOR rule (which includes the following four criteria: initial asystole, unwitnessed arrest, EMS-CPR duration > 20 min, and no prehospital ROSC) with a > 99% predictor of 1-month mortality is a reliable tool for physicians treating refractory OHCAs immediately after hospital arrival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03999-x.

Patient safety culture improvements depend on basic healthcare education: a longitudinal simulation-based intervention study at two Danish hospitals

Background

A growing body of evidence supports the existence of an association between patient safety culture (PSC) and patient outcomes. PSC refers to shared perceptions and attitudes towards norms, policies and procedures related to patient safety. Existing literature shows that PSC varies among health professionals depending on their specific profession and specialty. However, these studies did not investigate whether PSC can be improved. This study investigates whether length of education is associated with improvements in PCS following a simulation intervention.

Methods

From April 2017 to November 2018, a cross-sectional intervention study was conducted at two regional hospitals in Denmark. Two groups with altogether 1230 health professionals were invited to participate. One group included nurses, midwives and radiographers; the other group included doctors. A train-the-trainer intervention approach was applied consisting of a 4-day simulation instructor course that emphasised team training, communication and leadership. Fifty-three healthcare professionals were trained as instructors. After the course, instructors performed in situ simulation in their own hospital environment.

Outcomes

The Safety Attitude Questionnaire (SAQ), which has 6 dimensions and 32 items, was used to collect main outcome variables. All employees from both groups were surveyed before the intervention and again four and nine months after the intervention.

Results

Mean baseline scores were higher among doctors than among nurses, midwives and radiographers for all SAQ dimensions. At the second follow-up, four of six dimensions improved significantly (p ≤ 0.05) among nurses, midwives and radiographers, whereas no dimensions improved significantly among doctors.

Conclusion

Over time, nurses, midwives and radiographers improved more in PSC attitudes than doctors did.

Basic life support, a necessary inclusion in the medical curriculum: a cross-sectional survey of knowledge and attitude in Uganda

BACKGROUND

Uganda continues to depend on a health system without a well-defined emergency response system. This is in the face of the rising cases of out-of-hospital cardiac arrest contributed largely to the high incidence of road traffic accidents. Non-communicable diseases are also on the rise further increasing the incidence of cardiac arrest. Medical students are key players in the bid to strengthen the health system which warrants an assessment of their knowledge and attitude towards BLS inclusion in their study curriculum.

METHODS

A descriptive cross-sectional study was conducted in 2021 among undergraduate medical students across eight public and private universities in Uganda. An online-based questionnaire was developed using Google forms and distributed via identified WhatsApp groups. Chi-square or Fisher's exact test and logistic regression were performed in STATA 15 to assess the association between knowledge of BLS and demographics. P < 0.05 was considered statistically significant.

RESULTS

Out of the total 354 entries obtained, 351 were analyzed after eligibility screening. Of these, (n = 250, 71.2%) were male less than 25 years (n = 273, 77.8%). Less than half (n = 150, 42.7%) participants had undergone formal BLS training. Less than a third of participants (n = 103, 29.3%) had good knowledge (≥ 50%) with an overall score of 42.3 ± 12.4%. Age (p = 0.045), level of academic progress (p = 0.001), and prior BLS training (p = 0.033) were associated with good knowledge. Participants with prior training were more likely to have more BLS knowledge (aOR: 1.7, 95% CI: 1.1-2.7, p = 0.009). The majority (n = 348, 99.1%) believed that BLS was necessary and would wish (n = 343, 97.7%) to have it included in their curriculum.

CONCLUSIONS

Undergraduate medical students have poor BLS knowledge but understand its importance. Institutions need to adopt practical teaching methods such as clinical exposures, field experience in collaboration with local implementers, and participating in community health promotion campaigns.

Rapid degradation of psychomotor memory causes poor quality chest compressions in frequent cardiopulmonary resuscitation providers and feedback devices can only help to a limited degree: A crossover simulation study

Studies report a decline in the psychomotor memory of cardiopulmonary resuscitation (CPR) providers within months of training, but they are prone to subject bias. We hypothesized that this degradation is faster and more prevalent in real world practice. The aims of our study were to 1. assess the quality of chest compressions (CC) delivered routinely by CPR-certified clinicians who are not primed by study conditions, and 2. investigate if psychomotor memory degrades if feedback devices are removed. Forty anaesthetists and intensivists participated in a voluntary, half-day, randomized crossover study using case-based simulation. Participants were paired and randomly assigned into 2 groups; each receiving automated feedback either in the first or second cycle of CPR. Two cycles of CC and defibrillation (ACLS protocol) were administered on a manikin. CC parameters including overall quality were measured by a feedback device. The median proportion of good quality CC was poor at baseline but improved with feedback; 38.2% (IQR 27.7, 58.7) to 57.7% (IQR 38.0, 68.7), P < .05. The median proportion of good quality CC fell after feedback withdrawal; 50.5% (IQR 24.5, 67.7) to 25.6% (9, 37.6), P < .05. No carryover effect was observed. Treatment effect and period effect were detected. Baseline quality of CC amongst frequent CPR providers is poor, and can be improved partly by feedback devices. As psychomotor memory of good quality CCs degrades rapidly after removal of feedback, a multimodal approach is required for CPR skill retention. Future research on the optimal frequency of CPR training, including the use of feedback devices in clinical practice should be explored.

Basic Life Support Training for undergraduate nursing students: An integrative review

The aim of this review was to identify the role of basic life support training interventions in international undergraduate nursing education, that support optimal acquisition and retention of knowledge, psychomotor skills and resuscitation self-efficacy. Twenty-four articles were identified and analysed using an integrative review approach. Studies were reviewed for quality using a Critical Appraisal Skills Programme checklist. Common objective and standardised methods of basic life support education practice were identified: instructor led, simulation experiences, self-directed learning, skills training combined with clinical practicum, and computer-based training. Evaluation of competency was collected primarily from multiple-choice questionnaires or researcher-designed checklists, with a lack of objective performance data noted. Importantly, current teaching approaches do not guarantee acquisition or retention of basic life support skills. Objective feedback from technologies supporting cardiopulmonary resuscitation training may be useful in acquisition and retention of psychomotor skills, and therefore requires further exploration. Development of robust, psychometrically sound instruments are needed to accurately and consistently measure nursing students' skills performance.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Real-time audio-visual feedback with handheld nonautomated external defibrillator devices during cardiopulmonary resuscitation for in-hospital cardiac arrest: A meta-analysis

Objective:

Restoring cardiopulmonary circulation with effective chest compression remains the cornerstone of resuscitation, yet real-time compressions may be suboptimal. This project aims to determine whether in patients with in-hospital cardiac arrest (IHCA; population), chest compressions performed with free-standing audiovisual feedback (AVF) device as compared to standard manual chest compression (comparison) results in improved outcomes, including the sustained return of spontaneous circulation (ROSC), and survival to the intensive care unit (ICU) and hospital discharge (outcomes).

Methods:

Scholarly databases and relevant bibliographies were searched, as were clinical trial registries and relevant conference proceedings to limit publication bias. Studies were not limited by date, language, or publication status. Clinical randomized controlled trials (RCT) were included that enrolled adults (age ≥ 18 years) with IHCA and assessed real-time chest compressions delivered with either the standard manual technique or with AVF from a freestanding device not linked to an automated external defibrillator (AED) or automated compressor.

Results:

Four clinical trials met inclusion criteria and were included. No ongoing trials were identified. One RCT assessed the Ambu CardioPump (Ambu Inc., Columbia, MD, USA), whereas three assessed Cardio First Angel™ (Inotech, Nubberg, Germany). No clinical RCTs compared AVF devices head-to-head. Three RCTs were multi-center. Sustained ROSC (4 studies, n = 1064) was improved with AVF use (Relative risk [RR] 1.68, 95% confidence interval [CI] 1.39–2.04), as was survival to hospital discharge (2 studies, n = 922; RR 1.78, 95% CI 1.54–2.06) and survival to hospital discharge (3 studies, n = 984; RR 1.91, 95% CI 1.62–2.25).

Conclusion:

The moderate-quality evidence suggests that chest compressions performed using a non-AED free-standing AVF device during resuscitation for IHCA improves sustained ROSC and survival to ICU and hospital discharge.

Trial Registration:

PROSPERO (CRD42020157536).

Spaced learning versus massed learning in resuscitation - A systematic review

AIM

Skill decay is a recognised problem in resuscitation training. Spaced learning has been proposed as an intervention to optimise resuscitation skill performance compared to traditional massed learning. A systematic review was performed to answer 'In learners taking resuscitation courses, does spaced learning compared to massed learning improve educational outcomes and clinical outcomes?'

METHODS

This systematic review followed the PRISMA guidelines. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 2 December 2019. Randomised controlled trials and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using RoB, ROBINS-I tool and GRADEpro respectively. Educational outcomes studied were skill retention and performance 1 year after completion of training; skill performance between completion of training and 1 year; and knowledge at course conclusion. Clinical outcomes were skill performance at actual resuscitation, patient survival to discharge with favourable neurological outcome. This systematic review was registered in PROSPERO (CRD42019150358).

RESULTS

From 2,042 references, we included data from 17 studies (13 randomised studies, 4 cohort studies) in courses with manikins and simulation in the narrative synthesis. Eight studies reported results from basic life support training (with or without automatic external defibrillator); three studies reported from paediatric life support training; five were in neonatal resuscitation and one study reported results from a bespoke emergency medicine course which included resuscitation teaching. Fifteen out of seventeen studies reported improved performance with the use of spaced learning. The overall certainty of evidence was rated as very low for all outcomes primarily due to a very serious risk of bias. Heterogeneity across studies precluded any meta-analyses. There was a lack of data on the effectiveness of spaced learning on skill acquisition compared to maintaining skill performance and/or preventing skill decay. There was also insufficient data to examine the effectiveness of spaced learning on laypeople compared to healthcare providers.

CONCLUSIONS

Despite the very low certainty of evidence this systematic review suggests that spaced learning can improve skill performance at 1 year post course conclusion and skill performance between course conclusion and 1 year. There is a lack of data from this educational intervention on skill performance in clinical resuscitation and patient survival at discharge with favourable neurological outcomes.

A comparison of cardiopulmonary resuscitation with standard manual compressions versus compressions with real-time audiovisual feedback: A randomized controlled pilot study

Background:

Strategies that improve cardiopulmonary resuscitation (CPR) guideline adherence may improve in-hospital cardiac arrest (IHCA) outcomes. Real-time audiovisual feedback (AVF) is one strategy identified by the American Heart Association and the International Liaison Committee on Resuscitation as an area needing further investigation. The aim of this study was to determine if in patients with IHCA, does the addition of a free-standing AVF device to standard manual chest compressions during CPR improve sustained return of spontaneous circulation (ROSC) rates (primary outcome) or CPR quality or guideline adherence (secondary outcomes).

Methods:

This was a prospective, randomized, controlled, parallel study of patients undergoing resuscitation with chest compressions for IHCA in the mixed medical-surgical intensive care units (ICUs) of two academic teaching hospitals. Patients were randomized to receive either standard manual chest compressions or compressions using the Cardio First Angel™ feedback device.

Results:

Sixty-seven individuals were randomized, and 22 were included. CPR quality evaluation and guideline adherence scores were improved in the intervention group (P = 0.0005 for both). The incidence of ROSC was similar between groups (P = 0.64), as was survival to ICU discharge (P = 0.088) and survival to hospital discharge (P = 0.095).

Conclusion:

The use of the Cardio First Angel™ compression feedback device improved adherence to publish CPR guidelines and CPR quality. The insignificant change in rates of ROSC and survival to ICU or hospital discharge may have been related to small sample size. Further clinical studies comparing AVF devices to standard manual compressions are needed, as are device head-to-head comparisons.

Exploring individual and work organizational peculiarities of working in emergency medical communication centers in Norway- a qualitative study

Background

Emergency Medical call-takers working in Emergency Medical Communication Centers (EMCCs) are addressing complex and potentially life threatening problems. The call-takers have to make fast decisions, responding to problems described in phone calls. Recent studies focus mainly on individual aspects of call-takers’ work. The objectives of this study were to explore 1) What characterizes individual work performance of call takers in EMCCs? and 2) What characterizes work organizational factors call takers see as most relevant to the performance of their work?

Methods

The research is based upon in-depth interviews with call takers at three EMCCs in Norway (n = 19). Interviews were performed during the period May 2013 to September 2014. Data was analyzed using thematic analysis.

Results

Two main themes that related to individual work performance and to work organizational factors in EMCCs were identified, namely: 1) “Core technologies” and 2) “Environmental issues” . The theme “Core technologies” included the subthemes a) multiple tasks, b) critical incidents, and c) unpredictability. The theme “Environmental issues” included the subthemes a) lack of support, b) lack of resources, c) exposure to complaints, and d) an invisible service.

Conclusion

At the individual level, multiple tasks, how to cope with critical incidents, and the unpredictability of daily work when calls are received, make the work of call takers both stressful and challenging. The individual call taker’s ability to interprete the situation by intuition and experience when calls are received, is the main factor behind the peculiarities working in the centers at the individual level. At the organizational level, the lack of resources and managerial support seems to provoke concerns about the quality of services rendered by the centers. These aspects should be taken into account in the managing of these services, making them a more integrated part of the health service system.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4370-0) contains supplementary material, which is available to authorized users.

Laborious but Elaborate: The Benefits of Really Studying Team Dynamics

In this manuscript we discuss the consequences of methodological choices when studying team processes "in the wild." We chose teams in healthcare as the application because teamwork cannot only save lives but the processes constituting effective teamwork in healthcare are prototypical for teamwork as they range from decision-making (e.g., in multidisciplinary decision-making boards in cancer care) to leadership and coordination (e.g., in fast-paced, acute-care settings in trauma, surgery and anesthesia) to reflection and learning (e.g., in post-event clinical debriefings). We draw upon recently emphasized critique that much empirical team research has focused on describing team states rather than investigating how team processes dynamically unfurl over time and how these dynamics predict team outcomes. This focus on statics instead of dynamics limits the gain of applicable knowledge on team functioning in organizations. We first describe three examples from healthcare that reflect the importance, scope, and challenges of teamwork: multidisciplinary decision-making boards, fast-paced, acute care settings, and post-event clinical team debriefings. Second, we put the methodological approaches of how teamwork in these representative examples has mostly been studied centerstage (i.e., using mainly surveys, database reviews, and rating tools) and highlight how the resulting findings provide only limited insights into the actual team processes and the quality thereof, leaving little room for identifying and targeting success factors. Third, we discuss how methodical approaches that take dynamics into account (i.e., event- and time-based behavior observation and micro-level coding, social sensor-based measurement) would contribute to the science of teams by providing actionable knowledge about interaction processes of successful teamwork.

E-learning in advanced cardiac life support: Outcome and attitude among healthcare professionals

Background:

Advanced cardiac life support provides healthcare professionals with knowledge and skills needed in dealing with cardiac emergencies. By incorporating e-learning in advanced cardiac life support courses, it allows for easier accessibility of learning materials and a more personalized learning schedule at a lower overall cost.

Objectives:

This study aims to compare the outcome of e-learning advanced cardiac life support versus conventional advanced cardiac life support among healthcare professionals and determine their attitude on e-learning.

Methods:

A total of 96 candidates attending advanced cardiac life support courses in Hospital Universiti Sains Malaysia between January 2016 and May 2017 were included in the study. In total, 48 candidates were enrolled on each arm. Candidates in conventional advanced cardiac life support undertook a 2-day face-to-face course. Participants in e-learning advanced cardiac life support completed 6 h of online lecture videos prior to 1-day modified face-to-face course. All candidates were assessed by pre- and post-course multiple-choice questions and practical cardiac arrest simulation test. Only post-course and cardiac arrest simulation test marks contribute to the passing or failure of the candidates.

Results:

Candidates in e-learning advanced cardiac life support courses had higher mean scores on the pre-course multiple-choice questions (69.1, SD: 19.1) compared to those in conventional advanced cardiac life support courses (58.6, SD: 16.6, p < 0.001). The cardiac arrest simulation test pass rate on e-learning advanced cardiac life support was higher than conventional advanced cardiac life support courses although statistically not significant (95.8% vs 87.5%; p = 0.134). The overall pass rate was 93.8% for e-learning advanced cardiac life support versus 83.3% in conventional advanced cardiac life support (p = 0.099). A majority of the candidates had positive attitude towards e-learning.

Conclusion:

E-learning advanced cardiac life support courses demonstrated better results in terms of knowledge compared to conventional advanced cardiac life support, with equivalent skill scores. Shorter course duration, lesser cost and participants’ satisfaction were the added benefits. Further study can be done to explore the utilization of e-learning materials among healthcare professionals and its other advantages.

Improving skills retention after advanced structured resuscitation training: A systematic review of randomized controlled trials

AIMS

To systematically evaluate the literature on interventions that improve skills retention following advanced structured resuscitation training programs designed for healthcare professionals.

METHODS

A systematic review of MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO, ERIC, and Scopus was performed. Only randomized controlled trials investigating skills retention following advanced structured resuscitation training programs for healthcare professionals between inception to November 21, 2018 were included. Publications that assessed only knowledge acquisition were excluded. Relevant data from included studies were extracted and study quality was critically appraised, both independently and in duplicate by multiple reviewers. The risk of bias was assessed with the Cochrane Risk of Bias tool and the Medical Education Research Study Quality Instrument (MERSQI). Due to significant clinical heterogeneity in SRT training, study designs and interventions, a qualitative synthesis was used to summarize findings.

MAIN RESULTS

Sixteen studies, with a combined total of 1192 participants, were included in the final analysis. The majority of studies were conducted in North America and involved trainees or novice learners. ACLS was the most extensively studied, followed by NRP, ALS, and ATLS. Skills retention at 6 months was the most commonly used primary endpoint assessed using a simulated resuscitation checklist with either an adopted or created assessment tool. Most studies demonstrated a positive impact on skills retention when an interactive intervention or simulation was used. However, merely having a high-fidelity mannequin alone for simulation was found to have minimal effect on skills retention in the absence of other changes in content delivery. Booster sessions were found to be minimally effective in reinforcing long-term skills retention; however, most studies examining this intervention had small sample sizes and were underpowered.

CONCLUSIONS

Simulation-based interventions, refresher courses and adjustments to the content delivery of advanced structured resuscitation training courses were found to have the greatest impact on skills retention. However, due to significant heterogeneity and methodological flaws in the available studies, no definitive conclusions can be made regarding other interventions. Overall, there is a paucity of skills retention research and further high-quality randomized controlled trials are needed to determine the optimal intervention and design for resuscitation training that would maximize skills retention.

Associations between cardiopulmonary resuscitation (CPR) knowledge, self-efficacy, training history and willingness to perform CPR and CPR psychomotor skills: A systematic review

AIM

To determine whether training history (including number of times and duration since last training), knowledge, self-efficacy or willingness are associated with cardiopulmonary resuscitation (CPR) psychomotor skills.

METHODS

Eight databases were systematically searched from January 2005 to February 2018 for articles that involved adult layperson participants and explored an association between training history, knowledge, self-efficacy or willingness and CPR psychomotor skills or survival outcomes after real CPR attempts.

RESULTS

Thirty-four articles with a total of 35,421 participants were included. CPR training was found to improve psychomotor skills, compared to no training, and any previous training was associated with better skills, compared to no previous training, however only the use of a popular song promoted meaningful retention of a specifically targeted skill, compared to standard training methods. Skills deteriorated within 3 months, then plateaued from 3 to 6 months. Self-efficacy was weakly associated with skill level, however knowledge was not associated with skill level. No studies assessed the association between willingness and psychomotor skills.

CONCLUSION

All laypeople should attend an instructor-led CPR training session with real-time or delayed feedback to improve CPR skills. Training sessions should utilise combinations of validated skill-specific training strategies, preferably including popular songs and feedback to help ensure skills retention. Refresher training, which focusses on skills and self-confidence rather than knowledge, should be undertaken every 3-6 months, although this timeframe needs further validation. All future studies assessing CPR psychomotor skills should adhere to a standardised reporting outcome list (proposed in this paper) to ensure consistency and comparability of results.

Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial

Objective

To determine if real-time compression feedback using a non-automated hand-held device improves patient outcomes from in-hospital cardiac arrest (IHCA).

Methods

We conducted a prospective, randomized, controlled, parallel study (no crossover) of patients with IHCA in the mixed medical–surgical intensive care units (ICUs) of eight academic hospitals. Patients received either standard manual chest compressions or compressions performed with real-time feedback using the Cardio First Angel™ (CFA) device. The primary outcome was sustained return of spontaneous circulation (ROSC), and secondary outcomes were survival to ICU and hospital discharge.

Results

One thousand four hundred fifty-four subjects were randomized; 900 were included. Sustained ROSC was significantly improved in the CFA group (66.7% vs. 42.4%, P < 0.001), as was survival to ICU discharge (59.8% vs. 33.6%) and survival to hospital discharge (54% vs. 28.4%, P < 0.001). Outcomes were not affected by intra-group comparisons based on intubation status. ROSC, survival to ICU, and hospital discharge were noted to be improved in inter-group comparisons of non-intubated patients, but not intubated ones.

Conclusion

Use of the CFA compression feedback device improved event survival and survival to ICU and hospital discharge.

Trial registration

The study was registered with Clinicaltrials.gov (NCT02845011), registered retrospectively on July 21, 2016.

Continuous Education of Basic Life Support (BLS) through Social Media; a Quasi-Experimental Study

INTRODUCTION

It is imperative, if not fundamental, for medical students to receive continuing education in Basic life support (BLS). This present study aimed to investigate the effectiveness of continuing education using social media in this regard.

METHODS

In this quasi-experimental study, a questionnaire containing 20 items about BLS awareness was completed by the interns who were trained monthly in the emergency medicine training course. Then half of the interns received distant education through Telegram software up to three months, and the other did not receive any further education. Again, both groups completed the questionnaire at the end of the third month.

RESULTS

100 medical interns with the mean age of 25.05 ± 1.26 years were allocated to two groups of 50 subjects (65.0% female). Two groups were similar regarding the mean age (p = 0.304), gender (p = 0.529), mean awareness score at the beginning of the study (p = 0.916), and average pre-internship exam score (p = 0.080). The mean awareness score of medical interns increased significantly in intervention (11.44 ± 2.37 to 14.88 ± 1.97, p < 0.0001) and control (11.38 ± 3.22 to 12.54 ± 3.04, p < 0.0001) groups at second examination. But mean difference of awareness score, before and after the education, was significantly higher in intervention group (3.44 ± 1.48 versus 1.16 ± 1.51; p < 0.0001).

CONCLUSION

The increase in the BLS awareness score was significantly higher in medical interns who were continuously educated using Telegram social media software.

[Evaluation of a training model for health professionals in the care of critical patients: AIPCAP Study]

Objetivo

Evaluar la validez, aceptabilidad e impacto en el nivel de conocimientos y de habilidades de profesionales sanitarios de Atención Primaria de un modelo formativo para mejorar la atención del paciente crítico.

Diseño

Estudio multicéntrico de intervención cuasiexperimental.

Emplazamiento

En 8 equipos de Barcelona.

Participantes

En total 272 profesionales.

Intervenciones

Programa formativo con 48 simulacros de infarto agudo de miocardio (IAM) y de ictus.

Mediciones principales

Con una checklist se evaluaron las habilidades en el abordaje del paciente crítico, el efecto de la formación en los conocimientos de los participantes y la satisfacción. La formación se realizó tras 2 series de simulacros (infarto agudo de miocardio + ictus). En la segunda serie se efectuaron 3 evaluaciones: in situ, una semana después y a las 3 semanas. Se analizó la concordancia y la fiabilidad. Las diferencias de medias se analizaron mediante la t de Student para datos emparejados.

Resultados

Se respondieron 449 tests de conocimientos; la mayor puntuación se obtuvo al finalizar cada simulacro (3,89 [DE 1,01] vs. 3,21 [DE 1,09]). Obtuvieron mejores puntuaciones los médicos que las enfermeras (3,81 [DE 0,87] vs. 3,32 [DE 1,15]), y los profesionales con la especialidad finalizada que los MIR (3,6 [DE 1,08] vs. [DE 1,18]).

La puntuación media de la checklist en la primera evaluación fue de 7,7 puntos (DE 1,56), que mejoró hasta llegar a 9,1 puntos (DE 0,78).

El índice kappa fue mayor de 0,40 en todos los casos.

Conclusiones

Una metodología formativa para manejar urgencias en Atención Primaria con simulacros es válida, fiable y bien aceptada. Mejora el nivel de conocimientos y habilidades de los profesionales participantes.

Clinical instructors' perceptions of virtual reality in health professionals' cardiopulmonary resuscitation education

Objectives:

Cardiopulmonary resuscitation (CPR) is lifesaving. Yet, cardiac arrest survival remains low despite CPR intervention. Education has been highlighted as a strategy to overcome this issue. Virtual Reality technology has been gaining momentum in the field of clinical education. Published studies report benefits of virtual reality for CPR education; yet, perceptions of CPR instructors towards virtual reality remain unexplored. CPR instructors are key stakeholders in CPR education and their perceptions are valuable for the design and adoption of virtual reality-enhanced learning. The purpose of this study is therefore to understand the perceptions of CPR instructors towards using virtual reality for health professionals’ CPR education. The aim was addressed via three research questions: (1) What are the perceptions of CPR instructors towards current health professionals’ CPR education? (2) What are the perceptions of CPR instructors towards features of virtual reality ideal for health professionals’ CPR education? (3) What are the perceptions of CPR instructors towards the potential role of virtual reality in health professionals’ CPR education?

Methods:

A total of 30 CPR instructors were surveyed on their views towards current health professionals’ CPR education and the use of virtual reality for health professionals’ CPR education, before and after interacting with a CPR virtual reality simulation. Responses were analysed using interpretative thematic analysis.

Results:

CPR instructors perceived current health professionals’ CPR education as limited due to unideal test preparation (resources, practice, motivation, and frame of mind) and performance. They perceived fidelity, engagement, resource conservation, and memory enhancement as features of virtual reality ideal for health professionals’ CPR education. Virtual reality was viewed by CPR instructors as having potential as a blended learning tool, targeting both ‘novice’ and ‘experienced’ health professionals.

Conclusion:

The study highlighted the gaps in current health professionals’ CPR education that can be addressed using virtual-reality-enabled learning. Future research could investigate virtual reality simulations with features desirable for CPR education of target populations.

ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: A Consensus Statement

Despite significant advances in the field of resuscitation science, important knowledge gaps persist. Current guidelines for resuscitation are based on the International Liaison Committee on Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, which includes treatment recommendations supported by the available evidence. The writing group developed this consensus statement with the goal of focusing future research by addressing the knowledge gaps identified during and after the 2015 International Liaison Committee on Resuscitation evidence evaluation process. Key publications since the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations are referenced, along with known ongoing clinical trials that are likely to affect future guidelines.

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.

Return on investment in blended advanced cardiac life support training compared to face-to-face training in Singapore

Background

Internet adoption during the past decade has provided opportunities for innovation in advanced cardiac life support (ACLS) training. With pressure on budgets across health care systems, there is a need for more cost-effective solutions. Recently, traditional ACLS training has evolved from passive to active learning technologies. The objective of this study is to compare the cost, cost-savings and return on investment (ROI) of blended ACLS (B-ACLS) and face-to-face ACLS (F-ACLS) in Singapore.

Methods:

B-ACLS and F-ACLS courses are offered in two training institutes in Singapore. Direct and indirect costs of training were obtained from one of the training providers. ROI was computed using cost-savings over total cost if B-ACLS was used instead of F-ACLS.

Results:

The estimated annual cost to conduct B-ACLS and F-ACLS were S$43,467 and S$72,793, respectively. Discounted total cost of training over the life of the course (five years) was S$107,960 for B-ACLS and S$280,162 for F-ACLS. Annual productivity loss cost account for 52% and 23% of the costs among the F-ACLS and B-ACLS, respectively. B-ACLS yielded a 160% return on the money invested. There would be 61% savings over the life of the course if B-ACLS were to be used instead of F-ACLS.

Conclusion:

The B-ACLS course provides significant cost-savings to the provider and a positive ROI. B-ACLS should be more widely adopted as the preferred mode of ACLS training. As a start, physicians looking for reaccreditation of the ACLS training should be encouraged to take B-ACLS instead of F-ACLS.

Understanding patients and spouses experiences of patient education following a cardiac event and eliciting attitudes and preferences towards incorporating cardiopulmonary resuscitation training: A qualitative study

AIM

The aim of this study was to gain a comprehensive perspective about the experience of patient and spousal education following an acute cardiac event. The second objective was to elicit an understanding of patient and spousal attitudes, preferences and intentions towards future cardiopulmonary resuscitation training.

BACKGROUND

Patients with cardiovascular disease require comprehensive patient and family education to ensure adequate long-term disease management. As cardiac patients are at risk of future cardiac events, including out-of-hospital cardiac arrest, providing cardiopulmonary resuscitation training to patients and family members has long been advocated.

DESIGN

We conducted a qualitative study underpinned by phenomenology and the Theory of Planned Behaviour.

METHODS

Semi-structured interviews were conducted with cardiac patients and their spouses (N = 12 patient-spouse pairs) between March 2015-April 2016 purposively sampled from a cardiology ward. Interviews were transcribed verbatim and thematic analysis undertaken.

FINDINGS

Nine male and three female patients and their spouses were recruited. Ages ranged from 47-75 years. Four strongly interrelated themes emerged: the emotional response to the event, information, control and responsibility. There was evidence of positive attitudes and intentions from the TPB towards undertaking cardiopulmonary resuscitation training in the future. Only the eldest patient spouse pair were not interested in undertaking training.

CONCLUSIONS

Findings suggest cardiac patients and spouses have unmet education needs following an acute cardiac event. Information increased control and decreased negative emotions associated with diagnosis. Participants' preferences were for inclusion of cardiopulmonary resuscitation training in cardiac rehabilitation programs.

Metronome vs. Popular Song: A Comparison of Long-Term Retention of Chest Compression Skills after Layperson Training for Cardiopulmonary Resuscitation

Introduction

Long-term retention of cardiopulmonary resuscitation (CPR) skill is challenging for layperson trainees. This study compared the long-term retention of chest compression skills after either metronome-guided (MG) or popular song-guided (PG) CPR training.

Methods

This was a prospective randomised simulation trial. Untrained laypersons were randomly allocated to MG (n=61) or PG (n=68) groups at CPR training sessions. After CPR training, each participant performed 5-cycle CPR using a manikin with a Skill-Reporter™ immediately and six months afterwards.

Results

Immediately after training, the mean compression rate (MCR) was slightly higher in the PG than the MG group (107.4 vs. 102.2/min; p<0.0001), but there was no significant difference in the proportions of participants with an appropriate chest compression rate (100-120/min) (PSACCR) between the MG and PG (53/61 (86.9%) vs. 65/68 (95.6%); p=0.114). Six months later, MCR was faster in the MG than the PG (124.8 vs. 110.0/min; p<0.0001), and PSACCR in the PG was higher than that in the MG (62/68 (91.2%) vs. 25/61 (41.0%); p<0.0001). In both tests, there were no significant differences in other chest compression parameters of between the two groups, except for a minimal difference in incomplete chest release.

Conclusion

CPR training using a popular song is more effective than metronome-guided training in helping laypersons to maintain recommended compression rates after 6 months. (Hong Kong j.emerg.med. 2016;23:145-152)

The International Liaison Committee on Resuscitation-Review of the last 25 years and vision for the future

2017 marks the 25th anniversary of the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1992 to create a forum for collaboration among principal resuscitation councils worldwide. Since then, ILCOR has established and distinguished itself for its pioneering vision and leadership in resuscitation science. By systematically assessing the evidence for resuscitation standards and guidelines and by identifying national and regional differences, ILCOR reached consensus on international resuscitation guidelines in 2000, and on international science and treatment recommendations in 2005, 2010 and 2015. However, local variation and contextualization of guidelines are evident by subtle differences in regional and national resuscitation guidelines. ILCOR's efforts to date have enhanced international cooperation, and progressively more transparent and systematic collection and analysis of pertinent scientific evidence. Going forward, this sets the stage for ILCOR to pursue its vision to save more lives globally through resuscitation.

Telephone cardiopulmonary resuscitation is independently associated with improved survival and improved functional outcome after out-of-hospital cardiac arrest

AIM OF STUDY

This study aims to quantify the relative impact of Dispatcher-Initiated Telephone cardiopulmonary resuscitation (TCPR) on survival and survival with favorable functional outcome after out-of-hospital cardiac arrest (OHCA) in a population of patients served by multiple emergency dispatch centers and more than 130 emergency medical services (EMS) agencies.

METHODS

We conducted a retrospective, observational study of EMS-treated adult (≥18 years) patients with OHCA of presumed cardiac origin in Arizona, between January 1, 2011, and December 31, 2014. We compared survival and functional outcome among three distinct groups of OHCA patients: those who received no CPR before EMS arrival (no CPR group); those who received BCPR before EMS arrival and prior to or without telephone CPR instructions (BCPR group); and those who received TCPR (TCPR group).

RESULTS

In this study, 2310 of 4391 patients met the study criteria (median age, 62 years; IQR 50, 74; 1540 male). 32.8% received no CPR, 23.8% received Bystander-Initiated CPR and 43.4% received TCPR. Overall survival was 11.5%. Using no CPR as the reference group, the multivariate adjusted odds ratio for survival at hospital discharge was 1.51 (95% confidence interval [CI], 1.04, 2.18) for BCPR and 1.64 (95% CI, 1.16, 2.30) for TCPR. The multivariate adjusted odds ratio of favorable functional outcome at discharge was 1.58 (95% CI 1.05, 2.39) for BCPR and 1.56 (95% CI, 1.06, 2.31) for TCPR.

CONCLUSION

TCPR is independently associated with improved survival and improved functional outcome after OHCA.

e-Learning in Advanced Life Support-What factors influence assessment outcome?

AIM

To establish variables which are associated with favourable Advanced Life Support (ALS) course assessment outcomes, maximising learning effect.

METHOD

Between 1 January 2013 and 30 June 2014, 8218 individuals participated in a Resuscitation Council (UK) e-learning Advanced Life Support (e-ALS) course. Participants completed 5-8h of online e-learning prior to attending a one day face-to-face course. e-Learning access data were collected through the Learning Management System (LMS). All participants were assessed by a multiple choice questionnaire (MCQ) before and after the face-to-face aspect alongside a practical cardiac arrest simulation (CAS-Test). Participant demographics and assessment outcomes were analysed.

RESULTS

The mean post e-learning MCQ score was 83.7 (SD 7.3) and the mean post-course MCQ score was 87.7 (SD 7.9). The first attempt CAS-Test pass rate was 84.6% and overall pass rate 96.6%. Participants with previous ALS experience, ILS experience, or who were a core member of the resuscitation team performed better in the post-course MCQ, CAS-Test and overall assessment. Median time spent on the e-learning was 5.2h (IQR 3.7-7.1). There was a large range in the degree of access to e-learning content. Increased time spent accessing e-learning had no effect on the overall result (OR 0.98, P=0.367) on simulated learning outcome.

CONCLUSION

Clinical experience through membership of cardiac arrest teams and previous ILS or ALS training were independent predictors of performance on the ALS course whilst time spent accessing e-learning materials did not affect course outcomes. This supports the blended approach to e-ALS which allows participants to tailor their e-learning experience to their specific needs.

Factors associated with the outcome of out-of-hospital cardiopulmonary arrest among people over 80 years old in Japan

AIM

To determine if termination of resuscitation should be considered for older individuals, we sought to identify factors associated with clinical outcome following out-of-hospital cardiac arrest (OHCA) in people ≥80 years old and over.

METHODS

A prospective, population-based, observational study was conducted for ≥80-year-old individuals who experienced out-of-hospital cardiac arrest and to whom resuscitation was provided by emergency responders between January 1, 2005 and December 31, 2012 (n=377,577). The primary endpoint was 1-month survival. Signal detection analysis was applied to estimate predictive factors among 17 variables.

RESULTS

Among all out-of-hospital cardiac arrest cases, 59.4% were of cardiac origin, and 1-month survival rate was 3.3%. Following signal detection analysis, cases of both cardiac and non-cardiac origin were categorized into three subgroups defined by return of spontaneous circulation (ROSC) and epinephrine use. One-month survival ranged between 1.2 and 41.0% for the three subgroups of cardiac origin and between 2.0 and 41.1% for the three subgroups of non-cardiac origin.

CONCLUSIONS

ROSC was the most significant predictor of 1-month survival among patients with cardiac and non-cardiac OHCA who were ≥80 years old. Absence of ROSC might be an important factor to the termination of resuscitation rule for OHCA in individuals who are ≥80years old.

A study on the knowledge and attitudes on advanced life support among medical students and medical officers in a tertiary care hospital in Sri Lanka

Background

Advanced life support (ALS) and cardio pulmonary resuscitation, provided at the right time is essential for improving mortality in medical emergencies. Accurate knowledge and skills on this regard, in all medical personals is an essential part of medical education and it should be up to date with varying protocols. The aim of this study is to assess the knowledge and attitudes among the undergraduate medical students and medical officers in the Teaching Hospital Peradeniya and provide suggestions to improve the training programme on ALS.

Methods

A standardized self-administered questionnaire regarding knowledge and attitudes on ALS was filled by 4th and final year medical students, and medical officers, and the data was analyzed.

Results

There were 411 eligible candidates and of them 130 (31.6 %) were 4th year medical students, 221 (53.8 %) were final year medical students and 60 (14.6 %) were medical officers. Of the medical officers, only 15.8 % indicated that the internship training was adequate to handle an emergency confidently. Approximately 45 % of the medical officers and 34.6 % of the final year medical students were confident of saving lives with their current ALS knowledge. However, only 22 % of 4th year medical students were confident in saving the life of a patient.

Conclusions

Overall, just over 10 % of participants demonstrated inadequate ALS knowledge scores. A significantly higher proportion of final year medical students had good knowledge, compared to medical officers and 4th year students. Only one-third of participants were confident in saving a life with their current ALS knowledge. Nearly all participants thought that the ALS course should be reevaluated frequently.

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.

Newborn Resuscitation Training in Resource-Limited Settings: A Systematic Literature Review

CONTEXT

Birth asphyxia contributes substantially to neonatal mortality in low- and middle-income countries (LMICs). The effects of training birth attendants in neonatal resuscitation (NR) on mortality are limited by falloff of skills and knowledge over time and transference of learned skills into clinical practice.

OBJECTIVE

This review examined acquisition and retention of NR knowledge and skills by birth attendants in LMICs and the effectiveness of interventions to improve them.

DATA SOURCES

Medline, Cochrane, Embase, CINAHL, Bireme, and African Index Medicus databases were searched. We reviewed Web pages and reports from non-peer-reviewed (or "gray") literature sources addressing NR training in LMICs.

STUDY SELECTION

Articles on acquisition and retention of NR knowledge and skills, and interventions to improve them, were limited to LMICs.

RESULTS

The initial search identified 767 articles, of which 45 met all inclusion criteria. Of these, 31 articles analyzed acquisition of knowledge and skills, and 19 analyzed retention. Most studies found high acquisition rates, although birth attendants struggled to learn bag-mask ventilation. Although significant falloff of knowledge and skills occurred after training, refresher training seemed to improve retention. Results of the gray literature analysis suggest that formal, structured practice sessions improve retention.

LIMITATIONS

This review did not analyze training's direct impact on mortality.

CONCLUSIONS

Knowledge and skills falloff is a significant barrier to the success of NR training programs and possibly to reducing newborn mortality in LMICs. Refresher training and structured practice show significant promise. Additional research is needed to implement and assess retention improvement strategies in classroom and clinical settings.

Medical students and physical education students as CPR instructors: an appropriate solution to the CPR-instructor shortage in secondary schools?

Background

Integrating cardiopulmonary resuscitation (CPR) training in secondary schools will increase the number of potential CPR providers. However, currently too few certified instructors are available for this purpose. Training medical students and physical education student teachers to become CPR instructors could decrease this shortage.

Aim

Examine whether medical students and physical education student teachers can provide CPR training for secondary school pupils as well as (i. e., non-inferior to) registered nurses.

Methods

A total of 144 secondary school pupils were randomly assigned to CPR training by a registered nurse (n = 12), a  medical student (n = 17) or a physical education student teacher (n = 15). CPR performance was assessed after training and after eight weeks in a simulated cardiac arrest scenario on a resuscitation manikin, using manikin software and video recordings.

Results

No significant differences were found between the groups on the overall Cardiff Test scores and the correctness of the CPR techniques during the post-training and retention test. All pupils showed sufficient CPR competence, even after eight weeks.

Conclusion

Training by medical students or physical education student teachers is non-inferior to training by a registered nurse, suggesting that school teachers, student teachers and medical students can be recruited for CPR training in secondary schools.

Effect of mobile application-based versus DVD-based CPR training on students' practical CPR skills and willingness to act: a cluster randomised study

OBJECTIVES

The aim was to compare students' practical cardiopulmonary resuscitation (CPR) skills and willingness to perform bystander CPR, after a 30 min mobile application (app)-based versus a 50 min DVD-based training.

SETTINGS

Seventh grade students in two Swedish municipalities.

DESIGN

A cluster randomised trial. The classes were randomised to receive app-based or DVD-based training. Willingness to act and practical CPR skills were assessed, directly after training and at 6 months, by using a questionnaire and a PC Skill Reporting System. Data on CPR skills were registered in a modified version of the Cardiff test, where scores were given in 12 different categories, adding up to a total score of 12-48 points. Training and measurements were performed from December 2013 to October 2014.

PARTICIPANTS

63 classes or 1232 seventh grade students (13-year-old) were included in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary end point was the total score of the modified Cardiff test. The individual variables of the test and self-reported willingness to make a life-saving intervention were secondary end points.

RESULTS

The DVD-based group was superior to the app-based group in CPR skills; a total score of 36 (33-38) vs 33 (30-36) directly after training (p<0.001) and 33 (30-36) and 31 (28-34) at 6 months (p<0.001), respectively. At 6 months, the DVD group performed significantly better in 8 out of 12 CPR skill components. Both groups improved compression depth from baseline to follow-up. If a friend suffered cardiac arrest, 78% (DVD) versus 75% (app) would do compressions and ventilations, whereas only 31% (DVD) versus 32% (app) would perform standard CPR if the victim was a stranger.

CONCLUSIONS

At 6 months follow-up, the 50 min DVD-based group showed superior CPR skills compared with the 30 min app-based group. The groups did not differ in regard to willingness to make a life-saving effort.

The System-Wide Effect of Real-Time Audiovisual Feedback and Postevent Debriefing for In-Hospital Cardiac Arrest: The Cardiopulmonary Resuscitation Quality Improvement Initiative

OBJECTIVE

To evaluate the effect of implementing real-time audiovisual feedback with and without postevent debriefing on survival and quality of cardiopulmonary resuscitation quality at in-hospital cardiac arrest.

DESIGN

A two-phase, multicentre prospective cohort study.

SETTING

Three UK hospitals, all part of one National Health Service Acute Trust.

PATIENTS

One thousand three hundred and ninety-five adult patients who sustained an in-hospital cardiac arrest at the study hospitals and were treated by hospital emergency teams between November 2009 and May 2013.

INTERVENTIONS

During phase 1, quality of cardiopulmonary resuscitation and patient outcomes were measured with no intervention implemented. During phase 2, staff at hospital 1 received real-time audiovisual feedback, whereas staff at hospital 2 received real-time audiovisual feedback supplemented by postevent debriefing. No intervention was implemented at hospital 3 during phase 2.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was return of spontaneous circulation. Secondary endpoints included other patient-focused outcomes, such as survival to hospital discharge, and process-focused outcomes, such as chest compression depth. Random-effect logistic and linear regression models, adjusted for baseline patient characteristics, were used to analyze the effect of the interventions on study outcomes. In comparison with no intervention, neither real-time audiovisual feedback (adjusted odds ratio, 0.62; 95% CI, 0.31-1.22; p=0.17) nor real-time audiovisual feedback supplemented by postevent debriefing (adjusted odds ratio, 0.65; 95% CI, 0.35-1.21; p=0.17) was associated with a statistically significant improvement in return of spontaneous circulation or any process-focused outcome. Despite this, there was evidence of a system-wide improvement in phase 2, leading to improvements in return of spontaneous circulation (adjusted odds ratio, 1.87; 95% CI, 1.06-3.30; p=0.03) and process-focused outcomes.

CONCLUSIONS

Implementation of real-time audiovisual feedback with or without postevent debriefing did not lead to a measured improvement in patient or process-focused outcomes at individual hospital sites. However, there was an unexplained system-wide improvement in return of spontaneous circulation and process-focused outcomes during the second phase of the study.