Poor correlation of mouth-to-mouth ventilation skills after basic life support training and 6 months later

Factors Affecting Cardiopulmonary Resuscitation Practice Among Nurses in Mizan Tepi University Teaching Hospital, Tepi General Hospital, and Gebretsadik Shawo Hospital, Southwest Ethiopia

Background

Cardiopulmonary resuscitation is one of the basic lifesaving medical procedures which is performed for a patient with an emergency such as cardiac arrest, suffocation, near-dying, or circumstance that results in cardiac or pulmonary failure or both.

Objective

To assess factors affecting the practice of cardiopulmonary resuscitation among nurses at Mizan Tepi University Teaching Hospital, Tepi General Hospital, and Gebretsadik Shawo Hospital.

Methods

Institution-based cross-sectional study which was supported by qualitative data conducted from March 20 to April 20, 2021. Nurses who answered ≥7 CPR practice questions correctly were considered to have good practice. Data were entered into EpiData version 4.4 and exported to SPSS version 23 for data analysis. A multivariable logistic regression model was fitted, adjusted odds ratio (AOR) at 95% confidence interval and p-value <0.05 were estimated to determine the statistically significant association between predictors and outcome variable. Qualitative data were analyzed based on thematic content.

Results

The prevalence of good practice towards CPR was 31.8% (95% CI: 27.5-36.3) in the study area. Experience of 6-10 years (AOR = 2.27, 95% CI: 1.25-4.13) and >10 years (AOR= 1.81, 95% CI: 1.10-2.98), rarely (AOR = 3.77, 95% CI: 1.26-11.30) or actively (AOR = 4.60, 95% CI: 1.51-13.98) involved in CPR practice, assigned to emergency department (AOR = 1.02, 95% CI: 0.55-1.90), having CPR good knowledge (AOR = 1.37, 95% CI: 0.28-2.14) and having a nursing degree (AOR = 1.54, 95% CI: 0.93-2.54) were predictors of CPR good practice.

Conclusion

Nurses' good practice towards cardiopulmonary resuscitation was low. Therefore, efforts should be taken to enhance nurses' practice towards cardiopulmonary resuscitation.

Awareness of basic life support among Saudi dental students and interns

Objective:

Fatal medical emergencies may occur at any time in the dental clinic. The present study assessed the level of awareness and attitudes toward basic life support (BLS) among Saudi dental students and interns.

Materials and Methods:

A self-administered questionnaire comprising 23 closed-ended questions was used in this survey. The first part of the questionnaire assessed the demographical profile of the students such as age, gender, and educational level. The second part investigated their knowledge and awareness about BLS. Data from 203 respondents were analyzed using Statistical Package for the Social Studies version 22.0.

Results:

The response rate was 81.2%. Overall, the respondents showed a low level of knowledge with significant differences between males and females (<0.001). Surprisingly, final-year dental students showed relatively better knowledge than interns though the differences were not statistically significant.

Conclusion:

The present study demonstrates poor knowledge among dental students regarding BLS and showed the urgent need for continuous refreshing courses for this critical topic.

Professionalizing peer instructor skills in basic life support training for medical students: A randomized controlled trial

Background:

The Radboud university medical center designed an obligatory basic life support and first-aid course for first-year medical students.

Objectives:

We evaluated the value of an additional train-the-trainer course following European Resuscitation Council guidelines, which focuses on practical basic life support training and providing feedback, in comparison with standard in-service instructor training.

Methods:

This study was a prospective randomized controlled trial. A total of 10 intervention instructors, 14 control instructors, and 337 first-year medical students participated in the study. Students, blinded for the type of instructor, completed questionnaires evaluating the quality of the basic life support training (theoretical and practical) and provided feedback. The secondary endpoint was the basic life support examination to assess whether the instructors’ training influenced the quality of the participants’ basic life support.

Results:

The response rate of the questionnaire was 82% on average. No differences were found between intervention and control group concerning theoretical basic life support training. The intervention instructors scored significantly higher on practical basic life support training according to student evaluations ( p < 0.001). The pass rate on basic life support examinations did not differ significantly ( p = 0.669). Appreciation of given feedback was independent of instructors’ educational training.

Conclusion:

This study is the first to establish that the 12-h train-the-trainer course following European Resuscitation Council guidelines improves students’ appreciation of practical basic life support training. The additional course did not influence appreciation of theoretical basic life support training or perceived feedback.

Safety and applicability of a pre-stage public access ventilator for trained laypersons: a proof of principle study

BACKGROUND

Contemporary resuscitation guidelines for basic life support recommend an immediate onset of cardiac compressions in case of cardiac arrest followed by rescue breaths. Effective ventilation is often omitted due to fear of doing harm and fear of infectious diseases. In order to improve ventilation a pre-stage of an automatic respirator was developed for use by laypersons.

METHODS

Fifty-two healthy volunteers were ventilated by means of a prototype respirator via a full-face mask in a pilot study. The pre-stage public access ventilator (PAV) consisted of a low-cost self-designed turbine, with sensors for differential pressure, flow, FO₂, FCO₂ and 3-axis acceleration measurement. Sensor outputs were used to control the respirator and to recognize conditions relevant for efficiency of ventilation and patients' safety. Different respiratory manoeuvres were applied: a) pressure controlled ventilation (PCV), b) PCV with controlled leakage and c) PCV with simulated airway occlusion. Sensor signals were analysed to detect leakage and airway occlusion. Detection based upon sensor signals was compared with evaluation based on clinical observation and additional parameters such as exhaled CO₂.

RESULTS

Pressure controlled ventilation could be realized in all volunteers. Leakage was recognized with 93.5% sensitivity and 93.5% specificity. Simulated airway occlusion was detected with 91.8% sensitivity and 91.7% specificity.

CONCLUSION

The pre-stage PAV was able to detect potential complications relevant for patients' safety such as leakage and airway occlusion in a proof of principle study. Prospectively, this device provides a respectable basis for the development of an automatic emergency respirator and may help to improve bystander resuscitation.

[Saving lives with dispatcher-assisted resuscitation: importance of effective telephone instruction]

BACKGROUND

Survival rates after sudden cardiac arrest could be increased if bystanders could be encouraged to perform CPR until emergency services arrive. This should be initiated by the dispatcher at the emergency control facility who receives the call. For the first time the ERC guidelines of 2010 included instructions to be given to untrained rescuers by the dispatcher. Rapid recognition of cardiac arrest and initiation of emergency measures is assured by means of specific training for the dispatchers.

AIM

The aim of this investigation was to determine whether the time between an emergency call and beginning of cardiopulmonary resuscitation (CPR) could be shortened using a simple protocol and whether a relationship exists between the intensity of phone contact between dispatcher and caller and if this improves the results.

MATERIALS AND METHODS

In known cases of unconsciousness, group 1 (45 persons) received short CPR instructions via the phone, where the dispatcher was on the phone for continuous advice until emergency services arrived. Group 2 (45 persons) received identical phone instructions like group 1, but the phone call was terminated by the dispatcher after the information was provided. Group 3 (29 persons) only received instructions to start CPR.

RESULTS

On average, all test persons in group 1 started reanimation after 68.0 ± 33.5 s, in group 2 after 68.3 ± 25.2 s, and in group 3 after 64.9 ± 34.4 s. The compression frequency on average was 98.3/min in group 1, 84.8/min in group 2, and 85.2/min in group 3; therefore, all groups reached an average frequency of > 80/min. The correct compression depth was achieved by 47.8 % of test persons in group 1, by 44.2 % in group 2, and by 30.2 % in group 3. All volunteers felt well supported. Of the 90 people, 70 did not feel that they were missing instructions.

DISCUSSION

There were no significant differences between the groups regarding the target variables. The results show that already extremely short instructions or advice by the dispatcher to start CPR is sufficient to encourage bystanders to give assistance in an emergency. Continuous support over the phone does not appear to be necessary.

Basic life support: knowledge and attitude of medical/paramedical professionals

BACKGROUND

Basic life support (BLS), a key component of the chain of survival decreases the arrest - cardiopulmonary resuscitation interval and increases the rate of hospital discharge. The study aimed to explore the knowledge of and attitude towards basic life support (BLS) among medical/paramedical professionals.

METHODS

An observational study was conducted by assessing response to self prepared questionnaire consisting of the demographic information of the medical/paramedical staff, their personnel experience/attitude and knowledge of BLS based on the 2005 BLS Guidelines of European Resuscitation Council.

RESULTS

After excluding incomplete questionnaires, the data from 121 responders (27 clinical faculty members, 21 dental and basic sciences faculty members, 29 house officers and 44 nurses and health assistants) were analyzed. Only 9 (7.4%) of the 121 responders answered ≥11, 53 (43%) answered 7-10, and 58 (48%) answered <7 of 15 questions correctly. The clinical faculty members, house officers and nurses/HA had a mean score of 7.4±3.15, 7.37±2.02 and 6.63±2.16 respectively, while dental/basic sciences faculty members attained a least mean score of 4.52 ±2.13 (P<0.001). Those who had received cardiopulmonary resuscitation (CPR) training within 5 years obtained a highest mean score of 8.62±2.49, whereas those who had the training more than 5 years back or no training obtained a mean score of 5.54±2.38 and 6.1±2.29 respectively (P=0.001). Those who were involved in resuscitation frequently had a higher median score of 8 in comparison to those who were seldom involved or not involved at all (P<0.001).

CONCLUSIONS

The average health personnel in our hospital lack adequate knowledge in CPR/BLS. Training and experience can enhance knowledge of CPR of these personnel. Thus standard of CPR/BLS training and assessment are recommended at our hospital.

Effectiveness of basic life support instruction in physical education students--a pilot study

BACKGROUND

According to the literature, 40% of injuries affecting school-age children are sports related. The role of physical education students, as future teachers, seems to be of high importance in terms of protecting children's safety during sports classes.

PURPOSES

The aim is to evaluate the level of basic life support (BLS) knowledge and skills in physical education students instructed with the use of different methods.

METHODS

Second-year physical education students (n=104, M age=20±0.6 years) were randomly assigned to three groups: experimental 1 (E1), experimental 2 (E2), and control (C). Group E1 students participated in a 2-hour BLS course based on computer-assisted presentations. Group E2 trainees practiced BLS algorithm in pairs during a 2-hour course. No manikins were used in both intervention groups. Students of Group C were asked to learn BLS algorithm on their own. All groups fulfilled a 10-question multiple-choice test on BLS at the beginning and the end of the experiment. After completing the course participants performed BLS on a manikin.

RESULTS

The results of knowledge test were not significant before an experiment but differed essentially among the groups afterward (analysis of variance contrast analysis, p<.05). Regardless of teaching method used, no significant differences were found among the students in preparatory BLS actions and cardiopulmonary resuscitation (CPR) performance on a manikin. The level of CPR performance was very low in all groups.

CONCLUSIONS

Students of both intervention groups improved their BLS knowledge after the training. Teaching methods used in the current study seemed to be ineffective in terms of practical CPR skills. Access to greater number of modern manikins should improve the BLS training in physical education students. Moreover, permanent consultation on instructional methods with emergency medicine experts is recommended for university teachers.

Effectiveness of simulation on health profession students' knowledge, skills, confidence and satisfaction

Background  Despite the recent wave of interest being shown in high-fidelity simulators, they do not represent a new concept in healthcare education. Simulators have been a part of clinical education since the 1950s. The growth of patient simulation as a core educational tool has been driven by a number of factors. Declining inpatient populations, concerns for patient safety and advances in learning theory are forcing healthcare educators to look for alternatives to the traditional clinical encounter for skill acquisition for students. Objective  The aim of this review was to identify the best available evidence on the effectiveness of using simulated learning experiences in pre-licensure health profession education. Inclusion criteria  Types of studies: This review considered any experimental or quasi-experimental studies that addressed the effectiveness of using simulated learning experiences in pre-licensure health profession practice. In the absence of randomised controlled trials, other research designs were considered for inclusion, such as, but not limited to: non-randomised controlled trials and before-and-after studies.

TYPES OF PARTICIPANTS

This review included participants who were pre-licensure practitioners in nursing, medicine, and rehabilitation therapy. Types of intervention(s)/phenomena of interest: Studies that evaluated the use of human physical anatomical models with or without computer support, including whole-body or part-body simulators were included. Types of outcome measures  Student outcomes included knowledge acquisition, skill performance, learner satisfaction, critical thinking, self-confidence and role identity. Search strategy  Using a defined search and retrieval method, the following databases were accessed for the period 1995-2006: Medline, CINAHL, Embase, PsycINFO, HealthSTAR, Cochrane Database of Systematic Reviews and ERIC. Methodological quality  Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using the standardised critical appraisal instruments for evidence of effectiveness, developed by the Joanna Briggs Institute. Disagreements were dealt with by consultations with a third reviewer. Data collection  Information was extracted from each paper independently by two reviewers using the standardised data extraction tool from the Joanna Briggs Institute. Disagreements were dealt with by consultation with a third reviewer. Data synthesis  Due to the type of designs and quality of available studies, it was not possible to pool quantitative research study results in statistical meta-analysis. As statistical pooling was not possible, the findings are presented in descriptive narrative form. Results  Twenty-three studies were selected for inclusion in this review including partial task trainers and high-fidelity human patient simulators. The results indicate that there is high learner satisfaction with using simulators to learn clinical skills. The studies demonstrated that human patient simulators which are used for teaching higher level skills, such as airway management, and physiological concepts are useful. While there are short-term gains in knowledge and skill performance, it is evident that performance of skills over time after initial training decline. Conclusion  At best, simulation can be used as an adjunct for clinical practice, not a replacement for everyday practice. Students enjoyed the sessions and using the models purportedly makes learning easier. However, it remains unclear whether the skills learned through a simulation experience transfer into real-world settings. More research is needed to evaluate whether the skills acquired with this teaching methodology transfer to the practice setting such as the impact of simulation training on team function.

What is the impact of structured resuscitation training on healthcare practitioners, their clients and the wider service? A BEME systematic review: BEME Guide No. 20

A large number of resuscitation training courses (structured resuscitation training programmes (SRT)) take place in many countries in the world on a regular basis. This review aimed to determine whether after attending SRT programmes, the participants have a sustained retention of resuscitation knowledge and skills after their initial acquisition and whether there is an improvement in outcome for patients and/or their healthcare organisation after the institution of an SRT programme. All research designs were included, and the reported resuscitation training had to have been delivered in a predefined structured manner over a finite period of time. Data was extracted from the 105 eligible articles and research outcomes were assimilated in tabular form with qualitative synthesis of the findings to produce a narrative summary. Findings of the review were: SRTs result in an improvement in knowledge and skills in those who attend them, deterioration in skills and, to a lesser extent, knowledge is highly likely as early as three months following SRTs, booster or refresher sessions may improve an individual's ability to retain resuscitation skills after initial training and the instigation of resuscitation training in a healthcare institution significantly improves clinical management of resuscitations and patient outcome (including survival) after resuscitation attempts.

Benefits and shortcomings of mandatory first aid and basic life support courses for learner drivers

AIM

Annually, more than 127,000 people are killed and at least 2.4 million people injured in road accidents in Europe. Consequently, in half of all countries in the European Union a first aid and basic life support course has become mandatory for learner drivers. The aim of this study was to evaluate the effect of this course on participants' knowledge and self-assessed first aid and basic life support skills.

METHODS

Participants were given a questionnaire before and after course.

RESULTS

In total, 115 participants (response rate 98%) were included in the study. Mean age was 20 years (46% female and 54% male). Out of 12 questions, the average number of correct answers increased from 5.6 before the course to 8.7 after the course (p < 0.001). Upon completion of the course, 95% or more of the participants knew how to prioritise treatment of several casualties, knew how to relieve a foreign body airway obstruction, and knew the recommended compression-ventilation ratio during CPR (p < 0.001 for all). Despite significant improvements after the course only 64% knew how to diagnose cardiac arrest, 44% knew when to activate an automatic external defibrillator and 23% were aware of when to activate the emergency medical services. Participants significantly increased their self-confidence in own skills after the course (p < 0.001).

CONCLUSION

A mandatory course for learner drivers significantly improves participants' knowledge and their self-assessed skills in first aid and basic life support. However, improvements of the course should be considered on a number of key topics.

Head-position angles in children for opening the upper airway

AIMS

Inexperienced health-care-providers may encounter severe problems to ventilate an unconscious child. Designing a ventilating device that could indicate how to open an upper airway correctly may be beneficial. Neutral position in young children and slight head extension in older children is recommended, although the optimal head angle is not clear. Thus, we compared effects of neutral head position and extension, measuring head-position angles and ventilation parameters.

METHODS

Sixty-one children scheduled for tonsillectomy were enrolled, and were ventilated with pressure-controlled ventilation after anaesthesia induction.

RESULTS

Children were divided into two groups: 1-5 years old (pre-school children, n=38) and 6-10 years old (school children, n=23). In neutral (mean+/-SD: 1.3+/-6.0) vs. head-extension position (13.2+/-6.0; P<0.001) in pre-school children, tidal volumes (132+/-44,137+/-49 ml), peak-expiratory flow (300+/-90 vs. 310+/-100 mls(-1)) and expiratory airway resistance (20+/-8 vs. 18+/-6c mH(2)O s l(-1)) were comparable (P=NS). In neutral (-0.4+/-5.4) vs. head-extension position (15.7+/-6.4; P<0.001) in school children, expiratory airway resistance (17+/-7 vs. 13+/-5 cmH(2)O s l(-1); P=0.048) differed, while tidal volume (224+/-93 vs. 230+/-92 ml) and peak-expiratory flow (427+/-181 vs. 381+/-144 ml s(-1)) were comparable (P=NS).

CONCLUSIONS

Head-extension and neutral head-position angles differed in pre-school and school children. In pre-school children, neutral head position or head extension with an angle of -1 degrees or 13 degrees , and in school children head extension of 16 degrees , may be used to achieve optimal ventilation of an unprotected airway.

Effectiveness of simulation on health profession students' knowledge, skills, confidence and satisfaction

BACKGROUND

Despite the recent wave of interest being shown in high-fidelity simulators, they do not represent a new concept in healthcare education. Simulators have been a part of clinical education since the 1950s. The growth of patient simulation as a core educational tool has been driven by a number of factors. Declining inpatient populations, concerns for patient safety and advances in learning theory are forcing healthcare educators to look for alternatives to the traditional clinical encounter for skill acquisition for students.

OBJECTIVE

The aim of this review was to identify the best available evidence on the effectiveness of using simulated learning experiences in pre-licensure health profession education.

INCLUSION CRITERIA

Types of studies: This review considered any experimental or quasi-experimental studies that addressed the effectiveness of using simulated learning experiences in pre-licensure health profession practice. In the absence of randomised controlled trials, other research designs were considered for inclusion, such as, but not limited to: non-randomised controlled trials and before-and-after studies.

TYPES OF PARTICIPANTS

This review included participants who were pre-licensure practitioners in nursing, medicine, and rehabilitation therapy. Types of intervention(s)/phenomena of interest: Studies that evaluated the use of human physical anatomical models with or without computer support, including whole-body or part-body simulators were included.

TYPES OF OUTCOME MEASURES

Student outcomes included knowledge acquisition, skill performance, learner satisfaction, critical thinking, self-confidence and role identity.

SEARCH STRATEGY

Using a defined search and retrieval method, the following databases were accessed for the period 1995-2006: Medline, CINAHL, Embase, PsycINFO, HealthSTAR, Cochrane Database of Systematic Reviews and ERIC.

METHODOLOGICAL QUALITY

Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using the standardised critical appraisal instruments for evidence of effectiveness, developed by the Joanna Briggs Institute. Disagreements were dealt with by consultations with a third reviewer.

DATA COLLECTION

Information was extracted from each paper independently by two reviewers using the standardised data extraction tool from the Joanna Briggs Institute. Disagreements were dealt with by consultation with a third reviewer.

DATA SYNTHESIS

Due to the type of designs and quality of available studies, it was not possible to pool quantitative research study results in statistical meta-analysis. As statistical pooling was not possible, the findings are presented in descriptive narrative form.

RESULTS

Twenty-three studies were selected for inclusion in this review including partial task trainers and high-fidelity human patient simulators. The results indicate that there is high learner satisfaction with using simulators to learn clinical skills. The studies demonstrated that human patient simulators which are used for teaching higher level skills, such as airway management, and physiological concepts are useful. While there are short-term gains in knowledge and skill performance, it is evident that performance of skills over time after initial training decline.

CONCLUSION

At best, simulation can be used as an adjunct for clinical practice, not a replacement for everyday practice. Students enjoyed t he sessions and using the models purportedly makes learning easier. However, it remains unclear whether the skills learned through a simulation experience transfer into real-world settings. More research is needed to evaluate whether the skills acquired with this teaching methodology transfer to the practice setting such as the impact of simulation training on team function.

A web-based micro-simulation program for self-learning BLS skills and the use of an AED

AIM

Various methods, including self-instruction, have been used to try to improve the acquisition of basic life support skills. This is a preliminary report of the effectiveness of a web-based self-training program for BLS and the use of an AED.

METHODS

Sixteen volunteers completed on-line training in their own time over a period of 8 weeks. The program included theory, scenario training and self-testing, but without practice on a manikin, or any instructor input. The volunteers were assessed, without prior warning, in a scenario setting. A recording manikin, expert assessors and video recording were used with a modified version of the Cardiff Test.

RESULTS

All 16 volunteers performed the assessed skills in the use of an AED correctly. Most of the skills of BLS assessed were performed well. Chest compression depth and rate were performed less well (59% and 67% of participants, respectively, performed correctly). Opening the airway and lung inflation were performed poorly (38% and 13% of participants performed correctly), as was checking for safety (19% participants performed correctly). There was no significant correlation between the time a participant spent on-line and the quality of performance. Only 5 of the volunteers had ever attended a BLS course or used a resuscitation manikin before the assessment; their performance scores were not significantly better than those of the other 11 volunteers.

CONCLUSION

These results suggest that it may be possible to train people in BLS and AED skills using a micro-simulation web-based interactive program but without any practice on a manikin. This seems to be particularly the case for the use of an AED, where performance achieved a uniformly high standard.

The effect of time on CPR and automated external defibrillator skills in the Public Access Defibrillation Trial

BACKGROUND

The time to skill deterioration between primary training/retraining and further retraining in cardiopulmonary resuscitation (CPR) and automated external defibrillation (AED) for lay-persons is unclear. The Public Access Defibrillation (PAD) trial was a multi-center randomized controlled trial evaluating survival after CPR-only versus CPR+AED delivered by onsite non-medical volunteer responders in out-of-hospital cardiac arrest.

AIMS

This sub-study evaluated the relationship of time between primary training/retraining and further retraining on volunteer performance during pretest AED and CPR skill evaluation.

METHODS

Volunteers at 1260 facilities in 24 North American regions underwent training/retraining according to facility randomization, which included an initial session and a refresher session at approximately 6 months. Before the next retraining, a CPR and AED skill test was completed for 2729 volunteers. Primary outcome for the study was assessment of global competence of CPR or AED performance (adequate versus not adequate) using chi(2)-test for trends by time interval (3, 6, 9, and 12 months). Confirmatory (GEE) logistic regression analysis, adjusted for site and potential confounders was done.

RESULTS

The proportion of volunteers judged to be competent did not diminish by interval (3, 6, 9, and 12 months) for either CPR or AED skills. After adjusting for site and potential confounders, longer intervals to further retraining was associated with a slightly lower likelihood of performing adequate CPR but not with AED scores.

CONCLUSIONS

After primary training/retraining, the CPR skills of targeted lay responders deteriorate nominally but 80% remain competent up to 1 year. AED skills do not deteriorate significantly and 90% of volunteers remain competent up to 1 year.

An evaluation of objective feedback in basic life support (BLS) training

BACKGROUND

Studies show that acquisition and retention of BLS skills is poor, and this may contribute to low survival from cardiac arrest. Feedback from instructors during BLS training is often lacking. This study investigates the effects of continuous feedback from a manikin on chest compression and ventilation techniques during training compared to instructor feedback alone.

MATERIALS AND METHODS

A prospective randomised controlled trial. First-year healthcare students at the University of Birmingham were randomised to receive training in standard or feedback groups. The standard group were taught by an instructor using a conventional manikin. The feedback group used a 'Skillreporter' manikin, which provides continuous feedback on ventilation volume and chest compression depth and rate in addition to instructor feedback. Skill acquisition was tested immediately after training and 6 weeks later.

RESULTS

Ninety-eight participants were recruited (conventional n=49; Skillreporter n=49) and were tested after training. Sixty-six students returned (Skillreporter n=34; conventional n=32) for testing 6 weeks later. The Skillreporter group achieved better compression depth (39.96mm versus 36.71mm, P<0.05), and more correct compressions (58.0% versus 40.4%, P<0.05) at initial testing. The Skillreporter group also achieved more correct compressions at week 6 (43.1% versus 26.5%, P<0.05).

CONCLUSIONS

This study demonstrated that objective feedback during training improves the performance of BLS skills significantly when tested immediately after training and at re-testing 6 weeks later. However, CPR performance declined substantially over time in both groups.

Basic Life Support Ventilation in Mountain Rescue

Cardiopulmonary resuscitation in the mountains usually has to be performed under difficult and hostile circumstances and sometimes for extended periods of time. Therefore, mountain rescuers should have the ability and the appropriate equipment to perform prolonged, efficient, and safe ventilation. Members of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM) discussed the results of a literature review, focusing on the advantages and disadvantages of common ventilation techniques in basic life support and their training methods with specific respect to use in mountain rescue, and recommendations were proposed. Bystanders fear the potential risk of infection and lack the willingness to perform mouth-to-mouth ventilation, though the risk of infection is low. Mouth-to-mouth ventilation remains the standard technique for bystander ventilation and, in the absence of a barrier device, bystanders should not hesitate to ventilate a patient by this technique. For mountain rescue teams, we encourage the use of a barrier device for artificial ventilation. Mouth-to-mask ventilation devices are most likely to fulfill the requirements of being safe, simple, and efficient in the hands of a basic-trained rescuer. The use of a mouth-to-mask ventilation device is recommended for out-of-hospital ventilation in the mountains and should be part of the mountain rescuer's standard equipment. Bag-valve-mask ventilation is efficient, if performed by well-trained rescuers, but it leads to a low ventilation quality in the hands of a less experienced rescuer. It should be emphasized that regular training every 6 to 12 months is necessary to perform proper ventilation.

Head position for opening the upper airway

Inexperienced rescuers may encounter severe problems in an unconscious patient with opening and maintaining a patent upper airway. Designing a ventilating device that could indicate how to open an upper airway correctly may be beneficial. The heads of 102 volunteers were randomly placed in different head positions by one investigator. A pocket mask was then pressed gently on the volunteer's face followed by measurement of the head position angles. Mean (SD) flexion was - 4 degrees (8 degrees) (95% CI - 5.9 to - 2.9); the mean neutral position was 21 degrees (6 degrees) (95% CI, 19.9 to 22.3); extension was 42 degrees (6 degrees) (95% CI 40.8 to 43.0 degrees) and differed significantly between each position (p < 0.001). The flexion and neutral position angles were significantly greater in men than in women: - 2 (7 degrees) vs. -8 (7 degrees) and 22 (7 degrees) vs 20 (5 degrees); p < 0.001 and p = 0.03, respectively. Maximum extension of the head in both supine men and women was 42 degrees, which could be utilised to optimise assisted ventilation of an unprotected upper airway.

Quality of lay person CPR performance with compression: ventilation ratios 15:2, 30:2 or continuous chest compressions without ventilations on manikins

The new CPR guidelines emphasise chest compression depth and have increased the compression:ventilation ratio to cause less time intervals without chest compressions. How this change may influence the quality of chest compressions is not documented. Sixty-eight volunteers among travellers at Oslo international airport and a senior citizen centre performed 5 min of CPR on a manikin with compression:ventilation ratios 15:2, 30:2 or continuous chest compressions. Median age was 37.5 years (range 15-87), 59% were men, and 71% reported CPR training median 8 years (3-15) previously. Three of 22, 4 of 23 and 3 of 23 subjects in the 15:2, 30:2 and continuous compressions groups respectively stopped before 5 min had passed. Mean compression depth was 41 +/- 11, 45 +/- 8 and 30 +/- 8 mm, respectively. Depth was reduced as a function of time in the continuous compression group. Number of compressions per minute was 40 +/- 9, 43 +/- 14 and 73 +/- 24 and percent no flow time 49 +/- 13%, 38 +/- 20% and 1 +/- 2%, respectively. In conclusion, continuous chest compressions without ventilations gave significantly more chest compressions per minute, but with decreased compression quality. No flow time for 30:2 was significantly less than for 15:2.

The effects of teaching basic cardiopulmonary resuscitation--a comparison between first and sixth year medical students

The purpose of this study was to check if medical students of one of the Universities of Medical Sciences in Poland are prepared to do basic cardiopulmonary resuscitation. The research was undertaken on groups of 50 first year students and 50 sixth year students at the time when they take an exam. To have wider insight into students' ability to perform basic cardiopulmonary resuscitation, quantitative and qualitative methods were used. Students' knowledge of resuscitation was checked by a written test including open questions, their skills of doing resuscitation were checked on manikins. Students also completed a questionnaire. The results showed that first year medical students have a better knowledge of basic cardiopulmonary resuscitation compared with sixth year students. The skills of advanced cardiopulmonary resuscitation are better in sixth year students compared with first year students. The study showed that skills of ventilation and chest compressions need more practice. The students' own estimation of the ability to perform cardiopulmonary resuscitation both in the first and sixth years is very high, but it does not correlate with their knowledge and skills. Our conclusions indicate the need to improve the programme of teaching cardiopulmonary resuscitation with a refresher course in theory and skills at least once a year.

Predictors of cardiopulmonary resuscitation and automated external defibrillator skill retention

BACKGROUND

Few data exist regarding the retention of cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) skills over time in relationship to characteristics of lay volunteer responders, training, or risk of exposure to victims. The purpose of this study was to describe the characteristics associated with adequate CPR and AED skill retention.

METHODS AND RESULTS

Skill retention was tested 3 to 18 months (mean 6.9 +/- 3.5 months) after initial training. Instructors judged adequacy of performance of essential CPR or AED skills and provided an overall assessment (adequate/inadequate), which was used as the outcome. Data on 7261 laypersons trained in CPR (4358 also received AED training) in 24 sites across the United States and Canada were available from the Public Access Defibrillation (PAD) Trial. Characteristics of the volunteers, classes, and facilities were evaluated as predictors of performance adequacy. Adjusting for site, intervention assignment (CPR-only or CPR + AED), and time since initial training, volunteer characteristics associated with adequate CPR performance were age (OR 0.78 per 10-year increment), male sex (OR 1.44), minority (OR 0.62), married (OR 1.35), prior emergency experience (OR 1.66), prior CPR class (OR 1.68), prior advanced training (OR 1.59), and extracurricular CPR training (OR 1.91) (all P < .05). Characteristics associated with AED performance included age (OR 0.69), college education (OR 1.34), and native language other than English (OR 0.51) (all P < .05).

CONCLUSIONS

Certain subgroups of lay volunteers may need targeted outreach programs in CPR and AED use, classes with longer training time, more practice, or more intense retraining to maintain their CPR and/or AED skills.

Trained first-responders with an automated external defibrillator: how do they perform in real resuscitation attempts?

INTRODUCTION

The quality of first-responder performance at the end of automated external defibrillator (AED) training may not predict the performance adequately during a real resuscitation attempt.

METHODS

Between January and December 2000, we evaluated 67 resuscitation attempts in Amsterdam and surroundings, where police officers used an AED. We compared their performance with their assessment at the end of their ERC AED training course. One of the main goals of training was to deliver a shock within 90 s after switching the power on in the AED.

RESULTS

We analysed 127 police officers working in 67 police-teams. The police officers had a mean age of 35 years (range 23-54 years), 73% was male. The interval between AED training and the first resuscitation attempt was a median of 4 months (range 1-13). 78% percent of the 67 teams consisted of two police officers who both were qualified as "competent" after the initial training. Successful completion of the course correlated well with good performance during a resuscitation attempt (p = 0.009). When measured switching the power on in the AED, 92% of the victims received a shock within 90 s.

CONCLUSIONS

Successful training correlates well with successful performance in the field. Competence of a team may be better than competence of two separate individuals.

A randomized controlled trial of chest compression only CPR for older adults-a pilot study

Older people are trained infrequently in cardiopulmonary resuscitation (CPR), yet are more likely to witness a cardiac arrest. Older people who are CPR trained perform CPR when witnessing a cardiac arrest.

OBJECTIVE

To assess whether elderly adults (>55 years) who receive chest-compression only cardiopulmonary resuscitation (CC-CPR) training display equivalent skill retention rates compared with those who receive traditional CPR instruction. We also identified factors associated with 3 months skill retention at 3 months in both groups.

METHODS

Older adults in a suburban hospital Older Adult Services program were invited to participate in an experimental CPR course. The 2 h course was modelled after the AHA Friends and Family course, and used one of two standardized video scenarios. Seventy four subjects were randomized to CC-CPR (n=36) or traditional CPR (n=38) training. Participation consisted of initial training, followed by a 3 months return videotaped assessment. Three months skill competence was assessed either by consensus between two video evaluators, or the on-site evaluator. Chi square and Kappa tests were used for analysis, and unadjusted odds ratios and 95% confidence intervals are reported.

RESULTS

Skill retention assessments were completed on 29 (81%) CC-CPR and 26 (68%) CPR trainees. Subjects were elderly (71.5+/-6.69 years), and had a high rate of previous CPR training (58.0%). Groups were similar in demographic characteristics. After training, participants exhibited high rates of perceived competence (86.4%), although the overall 3 months skill retention was low (43.6%). CC-CPR training resulted in equivalent skill retention rates as compared with traditional CPR training (51.7 vs. 44.4%; P=0.586). No participant factors were associated with skill retention, including age, previous CPR training, education level, medical history, or perceived physical ability to perform.

CONCLUSION

We identified low rates of CPR skill retention in this elderly population. CC-CPR instruction was associated with equivalent skill retention rates compared with traditional CPR instruction. No demographic factors were associated with successful skill retention.

Knowledge of basic life support: a pilot study of the Turkish population by Baskent University in Ankara

A total of 494 participants who were scheduled to take Baskent University's basic life support (BLS) training programme in 2001-02 were asked to complete a 25-item questionnaire prior to the course. The questionnaire investigated the demographic characteristics of the subjects, their knowledge of the theoretical and practical aspects of BLS, and personal experience and attitudes related to BLS. The 'non-medical group' included 179 laypersons, and the 'medical group' was composed of medical students (n=220), residents (n=69) and clinical nurses (n=26). One-hundred and twenty-six (25.5%) of the participants had an encounter with some form of medical emergency event in their past and 207 (41.9%) had taken a BLS course previously. The most commonly cited anxiety about performing BLS was the fear of further harming the victim (56.9%). Nine of the participants said they would not perform mouth-to-mouth ventilation (1.8%). Compared to the other participants, individuals with previous emergency experience, and those who had previous BLS training answered significantly more of the theoretical questions correctly. However, neither of these groups performed significantly better than the other participants in the practical questions (P>0.05 for both comparisons). Based on our findings, we recommend that BLS training for medical undergraduates, other medical personnel and laypersons be improved and standardized throughout Turkey.

Comparison of different airway management strategies to ventilate apneic, nonpreoxygenated patients

OBJECTIVE

Endotracheal intubation is the gold standard for providing emergency ventilation, but acquiring and maintaining intubation skills may be difficult. Recent reports indicate that even in urban emergency medical services with a high call volume, esophageal intubations were observed, requiring either perfect intubation skills or development of alternatives for emergency ventilation.

DESIGN

Simulated emergency ventilation in apneic patients employing four different airway devices that used small tidal volumes.

SETTING

University hospital operating room.

SUBJECTS

Forty-eight ASA I/II patients who signed written informed consent before being enrolled into the study.

INTERVENTIONS

In healthy adult patients without underlying respiratory or cardiac disease who were breathing room air before undergoing routine induction of surgery, 12 experienced professional paramedics inserted either a laryngeal mask airway (n = 12), Combitube (n = 12), or cuffed oropharyngeal airway (n = 12) or placed a face mask (n = 12) before providing ventilation with a pediatric (maximum volume, 700 mL) self-inflating bag with 100% oxygen for 3 mins.

MEASUREMENTS AND MAIN RESULTS

In three of 12 cuffed oropharyngeal airway patients, two of 12 laryngeal mask airway patients, and one of 12 Combitube patients, oxygen saturation fell below 90% during airway device insertion, and the experiment was terminated; no oxygenation failures occurred with the bag-valve-mask. Oxygen saturation decreased significantly (p <.05) during insertion of the Combitube and laryngeal mask but not with the bag-valve-mask and cuffed oropharyngeal airway; however, oxygen saturation increased after 1 min of ventilation with 100% oxygen. No differences in tidal lung volumes were observed between airway devices.

CONCLUSIONS

Paramedics were able to employ the laryngeal mask airway, Combitube, and cuffed oropharyngeal airway in apneic patients with normal lung compliance and airways. In this population, bag-valve-mask ventilation was the most simple and successful strategy. Small tidal volumes applied with a pediatric self-inflating bag and 100% oxygen resulted in adequate oxygenation and ventilation.

First-aid training and bystander actions at traffic crashes--a population study

INTRODUCTION

Traffic crashes constitute a major, worldwide public-health problem that cause disabilities, life-long suffering, and huge economic losses. When a person is injured in a traffic crash, actions taken by bystanders often are of crucial importance. To perform first-aid actions in a correct manner, bystanders, often laypersons, need both the courage and the knowledge to do so. For preventive purposes, society spends large resources to inform and educate the public in order to enhance people's ability to take correct actions. However, there only is little information on the rate in a population of persons who have had first-aid training, have been bystanders at a traffic crash, on the actions taken by such persons, and on effects of first-aid training on patient care.

OBJECTIVE

The aim of this study was to acquire knowledge about: (1) the prevalence of first-aid training; (2) the incidence of being a bystander and of the first aid provided at traffic crashes and other emergencies; and (3) the impact of first-aid training on the risks people take in road traffic.

METHODS

A questionnaire was administered to 2,800 randomly selected persons aged 18-74 years.

RESULTS

The response rate was 67.5%. During the previous five years, 39% of the population had received first-aid training, with a higher rate among younger individuals and those with a higher education. After training, 30% of the respondents had used their skills, and 41% took fewer risks in traffic, particularly those who were older or had a lower level of education. Fourteen percent of those with training (significantly more men) had been bystanders at a traffic crash. At 20% of the crashes, a bystander had administered first aid, and one-third of those who provided such assistance had had use of their training.

CONCLUSION

Intensified first-aid training of the general public could lead to citizens who are more cautious in traffic and to bystanders who provide more immediate and adequate first aid at traffic crashes and other emergencies.

An automated voice advisory manikin system for training in basic life support without an instructor. A novel approach to CPR training

Twenty-four paramedic students with previous basic life support training were randomised, performing cardiopulmonary resuscitation (CPR) on a manikin for 3 min without any feedback followed by 3 min of CPR with audio feedback from the manikin after a 2-min break, or vice versa. A computer recorded information on timing, ventilation flow rates and volumes and all movements of the sternum of the manikin. The software allowed acceptable limits to be set for all ventilation and compression/release variables giving appropriate on-line audio feedback according to these settings from among approximately 40 pre-recorded messages. Students who started without feedback significantly improved after feedback in terms of the median percentage of correct inflations (from 2 to 64%), with most inflations being rapid before feedback (94%), compressions of correct depth (from 32 to 92%), and the duration of compressions in the duty cycle (from 41 to 44%). There were no problems with the median compression rate, sternal release during decompressions, or the hand position, even before feedback. There were no significant differences in any variables with and without feedback for the students who started with feedback, or between the audio feedback periods of the two groups. It is concluded that this automated voice advisory manikin system, a novel approach to basic CPR training, caused an immediate improvement in the skills performance of paramedic students.

The respiratory system during resuscitation: a review of the history, risk of infection during assisted ventilation, respiratory mechanics, and ventilation strategies for patients with an unprotected airway

The fear of acquiring infectious diseases has resulted in reluctance among healthcare professionals and the lay public to perform mouth-to-mouth ventilation. However, the benefit of basic life support for a patient in cardiopulmonary or respiratory arrest greatly outweighs the risk for secondary infection in the rescuer or the patient. The distribution of ventilation volume between lungs and stomach in the unprotected airway depends on patient variables such as lower oesophageal sphincter pressure, airway resistance and respiratory system compliance, and the technique applied while performing basic or advanced airway support, such as head position, inflation flow rate and time, which determine upper airway pressure. The combination of these variables determines gas distribution between the lungs and the oesophagus and subsequently, the stomach. During bag-valve-mask ventilation of patients in respiratory or cardiac arrest with oxygen supplementation (> or = 40% oxygen), a tidal volume of 6-7 ml kg(-1) ( approximately 500 ml) given over 1-2 s until the chest rises is recommended. For bag-valve-mask ventilation with room-air, a tidal volume of 10 ml kg(-1) (700-1000 ml) in an adult given over 2 s until the chest rises clearly is recommended. During mouth-to-mouth ventilation, a breath over 2 s sufficient to make the chest rise clearly (a tidal volume of approximately 10 ml kg(-1) approximately 700-1000 ml in an adult) is recommended.

Effectiveness of various airway management techniques in a bench model simulating a cardiac arrest patient

The purpose of this study was to assess the levels of lung and gastric tidal volumes paramedics achieve when performing ventilation with bag-valve-mask, laryngeal mask, and Combitube. Twenty paramedics performed ventilation with a bag-valve mask, laryngeal mask, and Combitube in a bench model simulating an unintubated cardiorespiratory arrest patient. Lung and gastric tidal volumes and lung and gastric peak airway pressures were subsequently measured. The results showed that mean +/- SEM lung tidal volumes were significantly higher with the laryngeal mask and Combitube compared to the bag-valve-mask (701 +/- 264 vs. 742 +/- 311 vs. 353 +/- 110 mL, respectively). No gastric inflation occurred with the Combitube; gastric inflation was significantly lower with the laryngeal mask compared to the bag-valve-mask (25 +/- 15 vs. 230 +/- 25 mL, respectively). Both the laryngeal mask and Combitube proved to be valid alternatives for bag-valve-mask ventilation in our bench model simulating an unintubated patient with cardiorespiratory arrest.

Obstacles to bystander cardiopulmonary resuscitation in Japan

OBJECTIVE

bystander cardiopulmonary resuscitation (CPR) is performed infrequently in Japan. We conducted this study to identify Japanese attitudes toward the performance of bystander CPR.

METHODS

participants were asked about their willingness to perform CPR with varying scenarios and CPR techniques (mouth-to-mouth ventilation plus chest compression (MMV plus CC) versus chest compression alone (CC)).

RESULTS

a total of 1302/1355 individuals completed the questionnaire, including high school students, teachers, emergency medical technicians, medical nurses, and medical students. About 2% of high school students, 3% of teachers, 26% of emergency medical technicians, 3% of medical nurses and 16% of medical students claimed they would 'definitely' perform MMV plus CC on a stranger. However, 21-72% claimed they would prefer the alternative of performing CC alone. Respondents claimed their unwillingness to perform MMV is not due to the fear of contracting a communicable disease, but the lack of confidence in their ability to perform CPR properly.

CONCLUSION

in all categories of respondents, willingness to perform MMV plus CC for a stranger was disappointingly low. Better training in MMV together with teaching awareness that CC alone can be given should be instituted to maximize the number of potential providers of CPR in the community, even in communities where the incidence of HIV is very low.

Life supporting first aid training of the public--review and recommendations

Since the introduction around 1960 of external cardiopulmonary resuscitation (CPR) basic life support (BLS) without equipment, i.e. steps A (airway control)-B (mouth-to-mouth breathing)-C (chest (cardiac) compressions), training courses by instructors have been provided, first to medical personnel and later to some but not all lay persons. At present, fewer than 30% of out-of-hospital resuscitation attempts are initiated by lay bystanders. The numbers of lives saved have remained suboptimal, in part because of a weak or absent first link in the life support chain. This review concerns education research aimed at helping more lay persons to acquire high life supporting first aid (LSFA) skill levels and to use these skills. In the 1960s, Safar and Laerdal studied and promoted self-training in LSFA, which includes: call for the ambulance (without abandoning the patient) (now also call for an automatic external defibrillator); CPR-BLS steps A-B-C; external hemorrhage control; and positioning for shock and unconsciousness (coma). LSFA steps are psychomotor skills. Organizations like the American Red Cross and the American Heart Association have produced instructor-courses of many more first aid skills, or for cardiac arrest only-not of LSFA skills needed by all suddenly comatose victims. Self-training methods might help all people acquire LSFA skills. Implementation is still lacking. Variable proportions of lay trainees evaluated, ranging from school children to elderly persons, were found capable of performing LSFA skills on manikins. Audio-tape or video-tape coached self-practice on manikins was more effective than instructor-courses. Mere viewing of demonstrations (e.g. televised films) without practice has enabled more persons to perform some skills effectively compared to untrained control groups. The quality of LSFA performance in the field and its impact on outcome of patients remain to be evaluated. Psychological factors have been associated with skill acquisition and retention, and motivational factors with application. Manikin practice proved necessary for best skill acquisition of steps B and C. Simplicity and repetition proved important. Repetitive television spots and brief internet movies for motivating and demonstrating would reach all people. LSFA should be part of basic health education. LSFA self-learning laboratories should be set up and maintained in schools and drivers' license stations. The trauma-focused steps of LSFA are important for 'buddy help' in military combat casualty care, and natural mass disasters.

A rationale for staged teaching of basic life support

Basic life support is a crucial part of the Chain of Survival. Unfortunately, however the skill is complex and cannot readily be acquired--let alone retained--in the course of a single training session. Although the problem has long been recognised, no new strategies have been widely implemented to counter the problem. We believe that staged teaching of CPR might provide a solution, and we have devised a program to test this new method. It involves three stages of instruction that we have called bronze, silver, and gold standards. The bronze standard involves opening the airway and providing chest compression without active ventilation: this alone may widen the window of opportunity for successful defibrillation in adult victims in out-of-hospital cardiac arrest. Ventilation is introduced at silver stage using a ratio of 50:5, with emphasis on its value in the resuscitation of children being used as motivation to bring people back for a second period of instruction. The gold stage teaches conventional CPR. A pilot study has been encouraging and a randomized trial on skill acquisition and skill retention is planned.

Special aspects of cardiopulmonary resuscitation: vasopressin as vasopressor, analysis of ventricular fibrillation waveform and tidal volume in an unintubated patient

Several laboratory studies have shown that vasopressin is a promising vasopressor during cardiopulmonary resuscitation; clinical investigations are currently being performed to determine whether vasopressin is superior compared with placebo or adrenaline during cardiopulmonary resuscitation. Ventricular fibrillation median frequency, dominant frequency, edge frequency and voltage amplitude can be used as noninvasive tools to monitor efficacy of ongoing cardiopulmonary resuscitation efforts. The newly recommended lower tidal volumes of 0.5 litres instead of 0.8-1.2 litres for ventilation of an unintubated cardiac arrest victim have been shown to be beneficial in mechanical models of an unprotected airway.