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Allert C, Nilsson B, Svensson A, Andersson EK. Voluntary first responders' experiences of being dispatched to suspected out-of-hospital cardiac arrest in rural areas: an interview study. BMC Cardiovasc Disord 2024; 24:157. [PMID: 38486144 PMCID: PMC10938808 DOI: 10.1186/s12872-024-03826-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 03/04/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a leading cause of death, and survival outcomes vary across countries and regions. To improve survival, the European Resuscitation Council Guidelines encourage the implementation of technologies like smartphone applications to alert voluntary first responders (VFRs) who are near a suspected OHCA. VFRs are of great importance in the ´chain of survival´, but there is still a lack of knowledge about their experiences; especially of those operating in rural areas. Understanding those experiences is crucial in developing appropriate interventions to train, encourage, and safeguard VFRs in their mission. Therefore, the aim of this study was to describe VFRs´ experiences of being dispatched to suspected OHCA in rural areas. METHODS The study used an inductive design. The data were collected using individual interviews with 16 VFRs and analysed using qualitative content analysis. RESULTS The results are presented in terms of six generic categories ''Being motivated and prepared'', ''Having strategies to undertake the mission'', ''Collaborating with others'', ''Being ethically aware'', ''Supporting the family members'', and ''Coping with the mission'', which formed the basis of the main category 'Desire to save lives and help others'. The findings showed that VFRs had a genuine desire to contribute to save lives in this rural area. Regardless of the circumstances, they were prepared to leave everything and act to the best for the victim and their family members. In theirs' missions they collaborated with others at the scene and were guided by ethics while they acted in complex circumstances. CONCLUSIONS VFRs dispatched in rural areas express a desire to save lives. In their missions, they acted in complex situations and experienced both emotional and ethical challenges. The design, implementation, and evaluation of support interventions directed at VFRs should be prioritised, especially in rural areas, as it can contribute to more people becoming and remaining VFRs, which in turn could contribute to sustainable development.
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Affiliation(s)
- Camilla Allert
- Department of Health and Caring Sciences, University Lecturer Faculty of Health and Life Sciences Linnaeus University, 392 31, Växjö/Kalmar, Sweden.
- Centre of Interprofessional Collaboration Within Emergency Care (CICE), Linnaeus University, Växjö, Sweden.
| | - Bengt Nilsson
- Department of Forestry and Wood Technology, Linnaeus University, Växjö, Sweden
- Centre of Interprofessional Collaboration Within Emergency Care (CICE), Linnaeus University, Växjö, Sweden
- Agunnaryd Voluntary Fire Brigade, Ljungby, Sweden
| | - Anders Svensson
- Department of Health and Caring Sciences, University Lecturer Faculty of Health and Life Sciences Linnaeus University, 392 31, Växjö/Kalmar, Sweden
- Centre of Interprofessional Collaboration Within Emergency Care (CICE), Linnaeus University, Växjö, Sweden
- Department of Ambulance Service, Region Kronoberg, Växjö, Sweden
| | - Ewa K Andersson
- Department of Health and Caring Sciences, University Lecturer Faculty of Health and Life Sciences Linnaeus University, 392 31, Växjö/Kalmar, Sweden
- Centre of Interprofessional Collaboration Within Emergency Care (CICE), Linnaeus University, Växjö, Sweden
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Charlton K, Bate A. Factors that influence paramedic decision-making about resuscitation for treatment of out of hospital cardiac arrest: Results of a discrete choice experiment in National Health Service ambulance trusts in England and Wales. Resusc Plus 2024; 17:100580. [PMID: 38380418 PMCID: PMC10877159 DOI: 10.1016/j.resplu.2024.100580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 02/22/2024] Open
Abstract
Background During out of hospital cardiac arrest (OHCA) paramedics must make decisions to commence, continue, terminate or withhold resuscitation. These decisions are known to be complex, subject to variability and often dependent on provider preference. This study aimed to understand paramedic decision-making regarding the commencement of resuscitation using a discrete choice experiment. Methods A discrete choice experiment between October-December 2022 surveying paramedics from ten National Health Service ambulance trusts in England and Wales. Respondents were presented with fourteen vignettes, each comprising thirteen attributes, and asked to decide if they would provide resuscitation or not. Results Eight hundred and sixty-four paramedics completed the survey (61.8% male, median age 36 years (IQR 17.1)) and half had < 5 years clinical experience (n = 443 (51.2%). Respondents expressed a general preference to offer resuscitation (p = <0.01). All attributes except patient gender were statistically significant and important regarding an offer of resuscitation. Cut-offs where an offer of resuscitation was less likely were patient age of 73 years (p=>0.05), mild dementia (p = >0.05) and moderate frailty (p = <0.01). Paramedic characteristics of female gender, longest (>10 years) and shortest (<5 years) period qualified, lower academic qualification, lower skill level and attending fewer OHCA's were more likely to result in an offer of resuscitation. Conclusion During OHCA paramedics use objective and non-objective factors to make pragmatic decisions regarding an offer of resuscitation. Future research should focus on how best to support paramedics to make decisions during OHCA, how variability in decision-making impacts patient outcomes and how this relates to patient and public expectations.
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Affiliation(s)
- Karl Charlton
- Research Paramedic, North East Ambulance Service NHS Foundation Trust, Bernicia House, Newburn Riverside, Newcastle upon Tyne, NE15 8NY, UK
| | - Angela Bate
- Associate Professor of Health Economics, Northumbria University, Sutherland Building, Northumberland Road, Newcastle upon Tyne, NE1 8ST, UK
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Sepahvand MJ, Nourozi K, Khankeh H, Mohammadi-Shahboulaghi F, Fallahi-Khoshknab M. Fears and Concerns of Bystanders to Help People Injured in Traffic Accidents: A Qualitative Descriptive Study. Emerg Med Int 2023; 2023:1862802. [PMID: 38099234 PMCID: PMC10721345 DOI: 10.1155/2023/1862802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/21/2023] [Accepted: 12/01/2023] [Indexed: 12/17/2023] Open
Abstract
In most traffic accidents, bystanders arrive at the scene before the rescuers. If they provide the right help, they can play an important and effective role in reducing the number of deaths and complications caused by these accidents. However, in many cases, fears and concerns prevent bystanders from providing assistance. This study aims to investigate and understand the fears and concerns of bystanders when they decide to help in traffic accidents. In 2022, this study was carried out in Iran using a qualitative content analysis approach. The data was collected through semistructured interviews. Participants were 15 males and females who had experience providing assistance in traffic accidents. Interviews, after digital recording, were transcribed verbatim. A purposeful and theoretical sampling method was performed. Data analysis and the determination of codes, categories, and subcategories were done using qualitative analysis software. O'Brien's qualitative research reporting standard was used. The results of the study include a category of fears and concerns and five subcategories. The subcategories include fear and concern caused by lack of information, fear of legal troubles, stress caused by previous experience, fear and anxiety caused by anticipation, and anxiety of unknown origin. The results of this study showed that some of the fears and concerns of the bystanders were related to a lack of information about providing assistance. By increasing bystanders' information about assistance, such as first aid training, fear and anxiety caused by a lack of information can be reduced. Another part of the fear and concern of bystanders is due to legal issues. Passing and implementing laws that protect bystanders can help reduce this fear and concern. Bystanders should be trained to provide assistance according to the rules of assistance so that they do not get into legal problems. A part of the bystander's fear and concern stems from their previous experiences providing assistance in traffic accidents. These experiences can also affect the fear and anxiety caused by anticipation. It is necessary to conduct more studies on the role of bystanders' experiences in creating fear and anxiety in them, as well as their effect on anticipatory fear.
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Affiliation(s)
| | - Kian Nourozi
- Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Hamidreza Khankeh
- Emergency and Disaster Health, University of Social Welfare and Rehabilitation Sciences, Associated at Department of Clinical Science and Education, Karolinska Institute, Tehran, Iran
| | - Farahnaz Mohammadi-Shahboulaghi
- Iranian Research Center on Aging, Nursing Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Masoud Fallahi-Khoshknab
- Department of Nursing, Iranian Scientific Association of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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4
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Milling L, Kjær J, Binderup LG, de Muckadell CS, Havshøj U, Christensen HC, Christensen EF, Lassen AT, Mikkelsen S, Nielsen D. Non-medical factors in prehospital resuscitation decision-making: a mixed-methods systematic review. Scand J Trauma Resusc Emerg Med 2022; 30:24. [PMID: 35346307 PMCID: PMC8962561 DOI: 10.1186/s13049-022-01004-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/25/2022] [Indexed: 11/10/2022] Open
Abstract
Aim This systematic review explored how non-medical factors influence the prehospital resuscitation providers’ decisions whether or not to resuscitate adult patients with cardiac arrest. Methods We conducted a mixed-methods systematic review with a narrative synthesis and searched for original quantitative, qualitative, and mixed-methods studies on non-medical factors influencing resuscitation of out-of-hospital cardiac arrest. Mixed-method reviews combine qualitative, quantitative, and mixed-method studies to answer complex multidisciplinary questions. Our inclusion criteria were peer-reviewed empirical-based studies concerning decision-making in prehospital resuscitation of adults > 18 years combined with non-medical factors. We excluded commentaries, case reports, editorials, and systematic reviews. After screening and full-text review, we undertook a sequential exploratory synthesis of the included studies, where qualitative data were synthesised first followed by a synthesis of the quantitative findings. Results We screened 15,693 studies, reviewed 163 full-text studies, and included 27 papers (12 qualitative, two mixed-method, and 13 quantitative papers). We identified five main themes and 13 subthemes related to decision-making in prehospital resuscitation. Especially the patient’s characteristics and the ethical aspects were included in decisions concerning resuscitation. The wishes and emotions of bystanders further influenced the decision-making. The prehospital resuscitation providers’ characteristics, experiences, emotions, values, and team interactions affected decision-making, as did external factors such as the emergency medical service system and the work environment, the legislation, and the cardiac arrest setting. Lastly, prehospital resuscitation providers’ had to navigate conflicts between jurisdiction and guidelines, and conflicting values and interests.
Conclusions Our findings underline the complexity in prehospital resuscitation decision-making and highlight the need for further research on non-medical factors in out-of-hospital cardiac arrest. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01004-6.
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Affiliation(s)
- Louise Milling
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark. .,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Jeannett Kjær
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lars Grassmé Binderup
- Philosophy, Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | | | - Ulrik Havshøj
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg University, Aalborg, Denmark.,Emergency Medical Services, Region North Denmark, Aalborg, Denmark
| | | | - Søren Mikkelsen
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Dorthe Nielsen
- Department of Infectious Diseases, Sub-Department of Immigrant Medicine, Odense University Hospital, Odense, Denmark.,Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
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Coppola A, Black S, Endacott R. How senior paramedics decide to cease resuscitation in pulseless electrical activity out of hospital cardiac arrest: a mixed methods study. Scand J Trauma Resusc Emerg Med 2021; 29:138. [PMID: 34530872 PMCID: PMC8447587 DOI: 10.1186/s13049-021-00946-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/26/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Evidenced-based guidelines on when to cease resuscitation for pulseless electrical activity are limited and support for paramedics typically defaults to the senior clinician. Senior clinicians include paramedics employed to work beyond the scope of clinical guidelines as there may be a point at which it is reasonable to cease resuscitation. To support these decisions, one ambulance service has applied a locally derived cessation of resuscitation checklist. This study aimed to describe the patient, clinical and system factors and examine senior clinician experiences when ceasing resuscitation for pulseless electrical activity. DESIGN AND METHODS An explanatory sequential mixed method study was conducted in one ambulance service in the South West of England. A consecutive sample of checklist data for adult pulseless electrical activity were retrieved from 1st December 2015 to 31st December 2018. Unexpected results which required exploration were identified and developed into semi-structured interview questions. A purposive sample of senior clinicians who ceased resuscitation and applied the checklist were interviewed. Content framework analysis was applied to the qualitative findings. RESULTS Senior clinicians ceased resuscitation for 50 patients in the presence of factors known to optimise survival: Witnessed cardiac arrest (n = 37, 74%), bystander resuscitation (n = 30, 60%), defibrillation (n = 22, 44%), return of spontaneous circulation (n = 8, 16%). Significant association was found between witnessed cardiac arrest and bystander resuscitation (p = .00). Six senior clinicians were interviewed, and analysis resulted in four themes: defining resuscitation futility, the impact of ceasing resuscitation, conflicting views and clinical decision tools. In the local context, senior clinicians applied their clinical judgement to balance survivability. Multiple factors were considered as the decision to cease resuscitation was not always clear. Senior clinicians deviated from the checklist when the patient was perceived as non-survivable. CONCLUSION Senior clinicians applied clinical judgement to assess patients as non-survivable or when continued resuscitation was considered harmful with no patient benefit. Senior clinicians perceived pre-existing factors with duration of resuscitation and clinical factors known to optimise patient survival. Future practice could look beyond a set criteria in which to cease resuscitation, however, it would be helpful to investigate the value or threshold of factors associated with patient outcome.
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Affiliation(s)
- Ali Coppola
- MClinRes Research Paramedic, South Western Ambulance Service NHS Foundation Trust, Abbey Court, Eagle Way, Exeter, UK.
| | - Sarah Black
- Head of Research, Audit and Quality Improvement, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Ruth Endacott
- School of Nursing and Midwifery (Faculty of Health: Medicine, Dentistry and Human Sciences), University of Plymouth, Plymouth, UK
- School of Nursing and Midwifery, (Faculty of Medicine, Nursing and Health Sciences), Monash University, Melbourne, Australia
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6
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Payot C, Fehlmann CA, Suppan L, Niquille M, Lardi C, Sarasin FP, Larribau R. Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168323. [PMID: 34444071 PMCID: PMC8391446 DOI: 10.3390/ijerph18168323] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/16/2022]
Abstract
The objective of this study was to identify the key elements used by prehospital emergency physicians (EP) to decide whether or not to attempt advanced life support (ALS) in asystolic out-of-hospital cardiac arrest (OHCA). From 1 January 2009 to 1 January 2017, all adult victims of asystolic OHCA in Geneva, Switzerland, were retrospectively included. Patients with signs of “obvious death” or with a Do-Not-Attempt-Resuscitation order were excluded. Patients were categorized as having received ALS if this was mentioned in the medical record, or, failing that, if at least one dose of adrenaline had been administered during cardiopulmonary resuscitation (CPR). Prognostic factors known at the time of EP’s decision were included in a multivariable logistic regression model. Included were 784 patients. Factors favourably influencing the decision to provide ALS were witnessed OHCA (OR = 2.14, 95% CI: 1.43–3.20) and bystander CPR (OR = 4.10, 95% CI: 2.28–7.39). Traumatic aetiology (OR = 0.04, 95% CI: 0.02–0.08), age > 80 years (OR = 0.14, 95% CI: 0.09–0.24) and a Charlson comorbidity index greater than 5 (OR = 0.12, 95% CI: 0.06–0.27) were the factors most strongly associated with the decision not to attempt ALS. Factors influencing the EP’s decision to attempt ALS in asystolic OHCA are the relatively young age of the patients, few comorbidities, presumed medical aetiology, witnessed OHCA and bystander CPR.
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Affiliation(s)
- Charles Payot
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, 1211 Geneva, Switzerland; (C.P.); (C.A.F.); (L.S.); (M.N.); (F.P.S.)
| | - Christophe A. Fehlmann
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, 1211 Geneva, Switzerland; (C.P.); (C.A.F.); (L.S.); (M.N.); (F.P.S.)
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1G 5Z3, Canada
- Emergency Medicine, Research Group, Ottawa Hospital Research Institute, Ottawa, ON K1Y 4E9, Canada
| | - Laurent Suppan
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, 1211 Geneva, Switzerland; (C.P.); (C.A.F.); (L.S.); (M.N.); (F.P.S.)
| | - Marc Niquille
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, 1211 Geneva, Switzerland; (C.P.); (C.A.F.); (L.S.); (M.N.); (F.P.S.)
| | - Christelle Lardi
- University Center of Legal Medicine (CURML), Geneva University Hospitals, 1211 Geneva, Switzerland;
| | - François P. Sarasin
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, 1211 Geneva, Switzerland; (C.P.); (C.A.F.); (L.S.); (M.N.); (F.P.S.)
| | - Robert Larribau
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, 1211 Geneva, Switzerland; (C.P.); (C.A.F.); (L.S.); (M.N.); (F.P.S.)
- Correspondence: ; Tel.: +41-79-553-9400
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7
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Milling L, Binderup LG, de Muckadell CS, Christensen EF, Lassen A, Christensen HC, Nielsen DS, Mikkelsen S. Documentation of ethically relevant information in out-of-hospital resuscitation is rare: a Danish nationwide observational study of 16,495 out-of-hospital cardiac arrests. BMC Med Ethics 2021; 22:82. [PMID: 34193147 PMCID: PMC8247191 DOI: 10.1186/s12910-021-00654-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/16/2021] [Indexed: 01/04/2023] Open
Abstract
Background Decision-making in out-of-hospital cardiac arrest should ideally include clinical and ethical factors. Little is known about the extent of ethical considerations and their influence on prehospital resuscitation. We aimed to determine the transparency in medical records regarding decision-making in prehospital resuscitation with a specific focus on ethically relevant information and consideration in resuscitation providers’ documentation. Methods This was a Danish nationwide retrospective observational study of out-of-hospital cardiac arrests from 2016 through 2018. After an initial screening using broadly defined inclusion criteria, two experienced philosophers performed a qualitative content analysis of the included medical records according to a preliminary codebook. We identified ethically relevant content in free-text fields and categorised the information according to Beauchamp and Childress’ four basic bioethical principles: autonomy, non-maleficence, beneficence, and justice.
Results Of 16,495 medical records, we identified 759 (4.6%) with potentially relevant information; 710 records (4.3%) contained ethically relevant information, whereas 49 did not. In general, the documentation was vague and unclear. We identified four kinds of ethically relevant information: patients’ wishes and perspectives on life; relatives’ wishes and perspectives on patients’ life; healthcare professionals’ opinions and perspectives on resuscitation; and do-not-resuscitate orders. We identified some “best practice” examples that included all perspectives of decision-making.
Conclusions There is sparse and unclear evidence on ethically relevant information in the medical records documenting resuscitation after out-of-hospital cardiac arrests. However, the “best practice” examples show that providing sufficient documentation of decision-making is, in fact, feasible. To ensure transparency surrounding prehospital decisions in cardiac arrests, we believe that it is necessary to ensure more systematic documentation of decision-making in prehospital resuscitation. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00654-y.
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Affiliation(s)
- Louise Milling
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark. .,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Lars Grassmé Binderup
- Philosophy, Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | | | | | - Annmarie Lassen
- Emergency Medicine Research Unit, Odense University Hospital, Odense, Denmark
| | | | - Dorthe Susanne Nielsen
- Department of Infectious Diseases, Sub-department of Immigrant Medicine, Odense University Hospital, Odense, Denmark.,Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
| | - Søren Mikkelsen
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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8
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de Graaf C, de Kruif AJTCM, Beesems SG, Koster RW. To transport or to terminate resuscitation on-site. What factors influence EMS decisions in patients without ROSC? A mixed-methods study. Resuscitation 2021; 164:84-92. [PMID: 34023427 DOI: 10.1016/j.resuscitation.2021.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/09/2021] [Accepted: 05/09/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND If a patient in out-of-hospital cardiac arrest (OHCA) does not achieve return of spontaneous circulation (ROSC) despite advanced life support, emergency medical services can decide to either transport the patient with ongoing CPR or terminate resuscitation on scene. PURPOSE To determine differences between patients without ROSC to be transported vs. terminated on scene and explore medical and nonmedical factors that contribute to the decision-making of paramedics on scene. METHODS Mixed-methods approach combining quantitative and qualitative data. Quantitative data on all-cause OHCA patients without ROSC on scene, between January 1, 2012, and December 31, 2016, in the Amsterdam Resuscitation Study database, were analyzed to find factors associated with decision to transport. Qualitative data was collected by performing 16 semi-structured interviews with paramedics from the study region, transcribed and coded to identify themes regarding OHCA decision-making on the scene. RESULTS In the quantitative Utstein dataset, of 5870 OHCA patients, 3190 (54%) patients did not achieve ROSC on scene. In a multivariable model, age (OR 0.98), public location (OR 2.70), bystander witnessed (OR 1.65), EMS witnessed (OR 9.03), and first rhythm VF/VT (OR 11.22) or PEA (OR 2.34), were independently associated with transport with ongoing CPR. The proportion of variance explained by the model was only 0.36. With the qualitative method, four main themes were identified: patient-related factors, local circumstances, paramedic-related factors, and the structure of the organization. CONCLUSION In patients without ROSC on scene, besides known resuscitation characteristics, the decision to transport a patient is largely determined by non-protocollized factors.
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Affiliation(s)
- Corina de Graaf
- Amsterdam UMC, Academic Medical Center (AMC), Heart Center, Department of Cardiology, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Anja J Th C M de Kruif
- Department of Epidemiology and Biostatistics, Amsterdam UMC location VUmc, Amsterdam, Amsterdam Public Health Research Institute, The Netherlands
| | - Stefanie G Beesems
- Amsterdam UMC, Academic Medical Center (AMC), Heart Center, Department of Cardiology, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Rudolph W Koster
- Amsterdam UMC, Academic Medical Center (AMC), Heart Center, Department of Cardiology, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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9
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Factors associated with physician decision making on withholding cardiopulmonary resuscitation in prehospital medicine. Sci Rep 2021; 11:5120. [PMID: 33664416 PMCID: PMC7933171 DOI: 10.1038/s41598-021-84718-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/15/2021] [Indexed: 12/29/2022] Open
Abstract
This study seeks to identify factors that are associated with decisions of prehospital physicians to start (continue, if ongoing) or withhold (terminate, if ongoing) CPR in patients with OHCA. We conducted a retrospective study using anonymised data from a prehospital physician response system. Data on patients attended for cardiac arrest between January 1st, 2010 and December 31st, 2018 except babies at birth were included. Logistic regression analysis with start of CPR by physicians as the dependent variable and possible associated factors as independent variables adjusted for anonymised physician identifiers was conducted. 1525 patient data sets were analysed. Obvious signs of death were present in 278 cases; in the remaining 1247, resuscitation was attempted in 920 (74%) and were withheld in 327 (26%). Factors significantly associated with higher likelihood of CPR by physicians (OR 95% CI) were resuscitation efforts by EMS before physician arrival (60.45, 19.89–184.29), first monitored heart rhythm (3.07, 1.21–7.79 for PEA; 29.25, 1.93–442. 51 for VF / pVT compared to asystole); advanced patient age (modelled using cubic splines), physician response time (0.92, 0.87–0.97 per minute) and malignancy (0.22, 0.05–0.92) were significantly associated with lower odds of CPR. We thus conclude that prehospital physicians make decisions to start or withhold resuscitation routinely and base those mostly on situational information and immediately available patient information known to impact outcomes.
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10
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Anderson NE, Slark J, Gott M. Prehospital Resuscitation Decision Making: A model of ambulance personnel experiences, preparation and support. Emerg Med Australas 2021; 33:697-702. [PMID: 33423356 DOI: 10.1111/1742-6723.13715] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/29/2020] [Accepted: 12/13/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This paper presents the first Naturalistic Decision Making model of prehospital resuscitation decision-making, which has clear implications for education, practice and support. METHODS A mixed-methods exploratory sequential research design consisting of interviews with ambulance personnel (study 1), focus groups with ambulance educators, managers and peer supporters (study 2), and an online survey of graduating paramedic students (study 3). This paper reports the model developed from integrated findings, across all three studies. All research was undertaken in New Zealand and underpinned by a critical realist worldview. RESULTS The Prehospital Resuscitation Decision Making model identifies key processes, challenges and facilitators before, during and after ambulance personnel attend a cardiac arrest event. It is the only descriptive model of resuscitation decision making which acknowledges the decision-maker, non-prognostic factors and the importance of adequate preparation and support. CONCLUSIONS This research project is the first to comprehensively explore and model ambulance personnel perspectives on decisions to start, continue or stop resuscitation. The decision-making process is complex and difficult to simply formularise. Education and supports must assist ambulance personnel in navigating this complexity. Where resuscitation is withheld or terminated, ambulance personnel need to feel confident that they can effectively provide after-death care.
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Affiliation(s)
- Natalie E Anderson
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Auckland Adult Emergency Department, Auckland District Health Board, Auckland, New Zealand
| | - Julia Slark
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Anderson NE, Robinson J, Moeke-Maxwell T, Gott M. Paramedic care of the dying, deceased and bereaved in Aotearoa, New Zealand. PROGRESS IN PALLIATIVE CARE 2020. [DOI: 10.1080/09699260.2020.1841877] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Natalie Elizabeth Anderson
- School of Nursing, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
- Auckland District Health Board, Auckland, New Zealand
| | - Jackie Robinson
- School of Nursing, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
- Auckland District Health Board, Auckland, New Zealand
| | - Tess Moeke-Maxwell
- School of Nursing, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
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12
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Sjölin H, Lindström V, Vicente V, Hult H, Ringsted C, Kurland L. Prehospital emergency nurses' experiences of care in critical incidents. Int Emerg Nurs 2020; 51:100890. [PMID: 32502944 DOI: 10.1016/j.ienj.2020.100890] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 05/06/2020] [Accepted: 05/12/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The ambulance care setting is complex and unpredictable and the personnel must prepare for upcoming assignments. Prehospital emergency care nurses (PENs), are frequently exposed to critical incidents (CIs). There are, to our knowledge, no prior studies describing experiences of requirements for management of caring for a patient during a CI in the ambulance care context. Therefore, the aim of the study was to explore PENs' experiences of care in CIs. METHOD A qualitative research design with content analysis has been used, based on semi-structured interviews with eleven PENs in Sweden. RESULTS PENs' experiences can be described as: "In a critical incident, personal ability based on experiential knowledge is central to patient care". Three generic categories underpinned the main category: "Clinical expertise", "Professional approach" and "Broad knowledge base". CONCLUSIONS The care given during a CI in the ambulance care setting depends on PENs' personal ability based on experiential knowledge. Employers need to build an organization providing prerequisites and support during an CI. Suggested activities are to create forums for PENs to share experiences with each other, possibility to get feedback on completed assignments and continued training to develop new knowledge and be prepared for the unpredictable environment that characterizes CI.
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Affiliation(s)
- Helena Sjölin
- Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Orebro, Sweden; Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Sweden.
| | - Veronica Lindström
- Academic EMS in Stockholm, Sweden; Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institute, Stockholm, Sweden.
| | - Veronica Vicente
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Sweden; Academic EMS in Stockholm, Sweden.
| | - Håkan Hult
- Department of CLINTEC, Karolinska Institute, Stockholm, Sweden.
| | - Charlotte Ringsted
- Centre for Health Science Education, Faculty of Health, Aarhus University, Aarhus, Denmark.
| | - Lisa Kurland
- Örebro University, Dept. of Medical Sciences, Örebro University Hospital, Dept. of Emergency Medicine, Sweden.
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13
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Leemeyer AMR, Van Lieshout EMM, Bouwens M, Breeman W, Verhofstad MHJ, Van Vledder MG. Decision making in prehospital traumatic cardiac arrest; A qualitative study. Injury 2020; 51:1196-1202. [PMID: 31926614 DOI: 10.1016/j.injury.2020.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/03/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite improving survival of patients in prehospital traumatic cardiac arrest (TCA), initiation and/or discontinuation of resuscitation of TCA patients remains a subject of debate among prehospital emergency medical service providers. The aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with TCA. METHODS Twenty-five semi-structured interviews were conducted with experienced ambulance nurses, HEMS nurses and HEMS physicians individually, followed by a focus group discussion. Participants had to be currently active in prehospital medicine in the Netherlands. Interviews were encoded for analysis using ATLAS.ti. Using qualitative analysis, different themes around decision making in TCA were identified. RESULTS Eight themes were identified as being important factors for decision making during prehospital TCA. These themes were: (1) factual information (e.g., electrocardiography rhythm or trauma mechanism); (2) fear of providing futile care or major impairment if return of spontaneous circulation was obtained; (3) potential organ donation; (4) patient age; (5) suspicion of attempted suicide; (6) presence of bystanders or family; (7) opinions of other team members; and (8) training and education. Several ambulance nurses reported they do not feel adequately supported by the current official national ambulance guidelines on TCA, nor did they feel sufficiently trained to perform pre-hospital interventions such as endotracheal intubation or needle thoracocentesis on these patients. CONCLUSION Eight themes were identified as being important for decision making during prehospital TCA. While guidelines based on prognostic factors are important, it should be recognized that decision making in TCA is impacted by more than factual information alone. This should be reflected in educational programs and future guidelines.
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Affiliation(s)
- Anna-Marie R Leemeyer
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Maneka Bouwens
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Wim Breeman
- AmbulanceZorg Rotterdam-Rijnmond, Barendrecht, the Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mark G Van Vledder
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Navalpotro-Pascual J, Lopez-Messa J, Fernández-Pérez C, Prieto-González M. Actitudes de los profesionales sanitarios ante la resucitación cardiopulmonar. Resultados de una encuesta. Med Intensiva 2020; 44:125-127. [DOI: 10.1016/j.medin.2018.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 09/11/2018] [Accepted: 09/21/2018] [Indexed: 10/27/2022]
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15
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Starks MA, Alexander K. In Anticipation of the Inevitable: Preparing Older Americans for Cardiac Arrest. J Am Geriatr Soc 2019; 68:9-10. [PMID: 31840229 DOI: 10.1111/jgs.16269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/01/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Monique Anderson Starks
- Preparing Older Americans for OHCA, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Karen Alexander
- Preparing Older Americans for OHCA, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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16
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Druwé P, Benoit DD, Monsieurs KG, Gagg J, Nakahara S, Alpert EA, van Schuppen H, Élő G, Huybrechts SA, Mpotos N, Joly LM, Xanthos T, Roessler M, Paal P, Cocchi MN, Bjørshol C, Nurmi J, Salmeron PP, Owczuk R, Svavarsdóttir H, Cimpoesu D, Raffay V, Pachys G, De Paepe P, Piers R. Cardiopulmonary Resuscitation in Adults Over 80: Outcome and the Perception of Appropriateness by Clinicians. J Am Geriatr Soc 2019; 68:39-45. [PMID: 31840239 DOI: 10.1111/jgs.16270] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 08/29/2019] [Accepted: 09/05/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out-of-hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome. DESIGN Subanalysis of an international multicenter cross-sectional survey (REAPPROPRIATE). SETTING Out-of-hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older. PARTICIPANTS A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics. RESULTS AND MEASUREMENTS The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the "appropriate" subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the "uncertain" subgroup, and 2 of 107 (1.9%) in the "inappropriate" subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non-shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non-shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate. CONCLUSION Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts. J Am Geriatr Soc 68:39-45, 2019.
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Affiliation(s)
- Patrick Druwé
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - James Gagg
- Department of Emergency Medicine, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | | | | | - Hans van Schuppen
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gábor Élő
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Sofie A Huybrechts
- Department of Emergency Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Nicolas Mpotos
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Luc-Marie Joly
- Department of Emergency Medicine, Rouen University Hospital, Rouen, France
| | - Theodoros Xanthos
- European University, Nicosia, Cyprus, Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - Markus Roessler
- Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Peter Paal
- Department of Anesthesiology and Critical Care Medicine, Hospitallers Brothers Hospital, Medical University Salzburg, Salzburg, Austria
| | - Michael N Cocchi
- Harvard Medical School, Department of Emergency Medicine and Department of Anesthesia Critical Care and Pain Medicine, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Conrad Bjørshol
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, The Regional Centre for Emergency Medical Research and Development (RAKOS), Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jouni Nurmi
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Radoslaw Owczuk
- Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Gdansk, Poland
| | | | - Diana Cimpoesu
- University of Medicine and Pharmacy Gr.T. Popa and Emergency County Hospital Sf. Spiridon, Iasi, Romania
| | | | - Gal Pachys
- Emergency Department, Sourasky Medical Center, Tel Aviv, Israel
| | - Peter De Paepe
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
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Is there an association between emergency physician gender and decision-making during out-of-hospital cardiac arrest? A retrospective study. Anaesth Crit Care Pain Med 2019; 38:661-663. [DOI: 10.1016/j.accpm.2019.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 05/07/2019] [Accepted: 05/11/2019] [Indexed: 11/18/2022]
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Anderson NE, Slark J, Faasse K, Gott M. Paramedic student confidence, concerns, learning and experience with resuscitation decision-making and patient death: A pilot survey. Australas Emerg Care 2019; 22:156-161. [DOI: 10.1016/j.auec.2019.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/25/2019] [Accepted: 07/01/2019] [Indexed: 11/26/2022]
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Anderson NE. Unlocking intuition and expertise: using interpretative phenomenological analysis to explore clinical decision making. J Res Nurs 2019; 24:88-101. [PMID: 34394511 PMCID: PMC7932448 DOI: 10.1177/1744987118809528] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Clinical decision making is a complex, but important, research area. Decision-making theories have evolved to recognise that, although heuristics and biases can lead to error, expert clinician decision makers can also use intuition to good effect. More research is needed to understand how nurses and other clinicians make sense of complexity and uncertainty. AIM This paper discusses the utility of interpretative phenomenological analysis to elucidate clinical decision making, expertise and intuition. METHODS A narrative review of published interpretative phenomenological analysis studies exploring clinical decision-making, and discussion of an exemplar study. RESULTS A limited number of interpretative phenomenological analysis studies have been published in this area. By seeking out descriptions of real-world decision making, interpretative phenomenological analysis research provides ecologically valid insights into what it is like to make time-critical, high-stakes decisions with limited information. CONCLUSION Contributing to the study of complex clinical decision making in combination with other research approaches, interpretative phenomenological analysis research has significant unrealised potential to inform education, assessment and support interventions and the development of clinical guidelines. Future applications could enhance understanding of multi-disciplinary decision-making and the development of expertise and intuition, over time.
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Affiliation(s)
- Natalie Elizabeth Anderson
- Professional Teaching Fellow and Doctoral Candidate,
School of Nursing, University of Auckland, New Zealand; Registered Nurse,
Auckland Adult Emergency Department, Auckland District Health Board, New
Zealand
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Anderson NE, Gott M, Slark J. Grey areas: New Zealand ambulance personnel’s experiences of challenging resuscitation decision-making. Int Emerg Nurs 2018; 39:62-67. [DOI: 10.1016/j.ienj.2017.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 07/30/2017] [Accepted: 08/04/2017] [Indexed: 11/24/2022]
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Ketelaars R, Beekers C, Van Geffen GJ, Scheffer GJ, Hoogerwerf N. Prehospital Echocardiography During Resuscitation Impacts Treatment in a Physician-Staffed Helicopter Emergency Medical Service: an Observational Study. PREHOSP EMERG CARE 2018; 22:406-413. [PMID: 29469616 DOI: 10.1080/10903127.2017.1416208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Patients in cardiac arrest must receive algorithm-based management such as basic life support and advanced (cardiac) life support. International guidelines dictate diagnosing and treating any factor that may have caused the arrest or may be complicating the resuscitation. Ultrasound may be of potential value in this process and can be used in a prehospital setting. The objective is to evaluate the use of prehospital ultrasound during traumatic and non-traumatic CPR and determine its impact on prehospital treatment decisions in a Dutch helicopter emergency medical service (HEMS). METHODS We conducted an observational study in cardiac arrest patients, of any cause, in whom the Nijmegen HEMS performed CPR with concurrent echocardiography. The participating physicians had to adhere to Advanced Life Support protocols as per standard operating procedure. Simultaneous with the interruptions of chest compressions to allow for heart rhythm analysis, ultrasound-trained HEMS physicians performed echocardiography according to study protocol. The HEMS nurse and physician recorded patient data and data on impacted (supported or altered) patient treatment decisions. RESULTS From February 2014 through November 2016, we included 56 patients who underwent 102 ultrasound examinations. Sixty-two (61%) ultrasound examinations impacted 78 treatment decisions in 49 patients (88%). The impacted treatment was related to termination of CPR in 32 (57%), fluid management (14%), drugs selection and doses (14%), and choice of destination hospital (5%). Causes of cardiac arrest included trauma (48%), cardiac (21%), medical (14%), asphyxia (9%), and other (7%). CONCLUSION Prehospital echocardiography has an impact on patient treatment and may be a useful tool to support decision-making during CPR in a Dutch HEMS.
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Anderson NE, Gott M, Slark J. Beyond prognostication: ambulance personnel’s lived experiences of cardiac arrest decision-making. Emerg Med J 2018; 35:208-213. [DOI: 10.1136/emermed-2017-206743] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 12/13/2017] [Accepted: 12/18/2017] [Indexed: 11/04/2022]
Abstract
IntroductionThe purpose of this study was to explore ambulance personnel’s decisions to commence, continue, withhold or terminate resuscitation efforts for patients with out-of-hospital cardiac arrest.MethodSemistructured interviews with a purposive sample of 16 demographically diverse ambulance personnel, currently employed in a variety of emergency ambulance response roles, around New Zealand.ResultsParticipants sought and integrated numerous factors, beyond established prognostic indicators, when making resuscitation decisions. Factors appeared to be integrated in four distinct phases, described under four main identified themes: prearrival impressions, immediate on-scene impressions, piecing together the big picture and transition to termination of resuscitation. Commencing or continuing resuscitation was sometimes a default action, particularly where ambulance personnel felt the context was uncertain, unfamiliar or overwhelming. Managing the impact of termination of resuscitation and resulting scene of a death required significant confidence, psychosocial skills and experience.ConclusionThis unique, exploratory study provides new insights into ambulance personnel’s experiences of prehospital resuscitation decision-making. Prognostication in out-of-hospital cardiac arrest is known to be challenging, but results from this study suggest that confidence in a poor prognosis for the cardiac arrested patient is only part of the resuscitation decision-making picture. Results suggest ambulance personnel may benefit from greater educational preparation and mentoring in managing the scene of a death to avoid inappropriate or prolonged resuscitation efforts.
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Brandling J, Kirby K, Black S, Voss S, Benger J. Emergency medical service provider decision-making in out of hospital cardiac arrest: an exploratory study. BMC Emerg Med 2017; 17:24. [PMID: 28743232 PMCID: PMC5526270 DOI: 10.1186/s12873-017-0136-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 07/17/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are approximately 60,000 out-of-hospital cardiac arrests (OHCA) in the United Kingdom (UK) each year. Within the UK there are well-established clinical practice guidelines that define when resuscitation should be commenced in OHCA, and when resuscitation should cease. Background literature indicates that decision-making in the commencement and cessation of resuscitation efforts in OHCA is complex, and not comprehensively understood. No relevant research from the UK has been published to date and this research study seeks to explore the influences on UK Emergency Medical Service (EMS) provider decision-making when commencing and ceasing resuscitation attempts in OHCA. The aim of this research to explore the influences on UK Emergency Medical Services provider decision-making when commencing and ceasing resuscitation attempts in OHCA. METHODS Four focus groups were convened with 16 clinically active EMS providers. Four case vignettes were discussed to explore decision-making within the focus groups. Thematic analysis was used to analyse transcripts. RESULTS This research found that there are three stages in the decision-making process when EMS providers consider whether to commence or cease resuscitation attempts in OHCA. These stages are: the call; arrival on scene; the protocol. Influential factors present at each of the three stages can lead to different decisions and variability in practice. These influences are: factual information available to the EMS provider; structural factors such as protocol, guidance and research; cultural beliefs and values; interpersonal factors; risk factors; personal values and beliefs. CONCLUSIONS An improved understanding of the circumstantial, individual and interpersonal factors that mediate the decision-making process in clinical practice could inform the development of more effective clinical guidelines, education and clinical decision support in OHCA. These changes have the potential to lead to greater consistency. and EMS provider confidence, with the potential for improved patient outcome from OHCA.
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Affiliation(s)
- J Brandling
- University of the West of England, Bristol, UK
| | - K Kirby
- South Western Ambulance Service NHS Foundation Trust, Dorchester, UK.
| | - S Black
- South Western Ambulance Service NHS Foundation Trust, Dorchester, UK
| | - S Voss
- University of the West of England, Bristol, UK
| | - J Benger
- University of the West of England, Bristol, UK
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