Impact of Personal Protective Equipment on Pediatric Cardiopulmonary Resuscitation Performance: A Controlled Trial

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Assessing the New Norm: A Simulation Study to Assess Pediatric Emergency Physician Success in Critical Procedures With an Air Purifying Respirator

INTRODUCTION

Physicians caring for patients with COVID-19 are at high risk for contracting the disease, thus, significant emphasis has been placed on personal protective equipment (PPE). The study aims to assess the impact of advanced PPE across 4 common procedures: endotracheal intubation, bag-valve mask ventilation, intraosseous (IO) insertion, and lumbar puncture (LP) performed by pediatric emergency physicians.

METHOD

Physicians performed the procedures in a simulated environment. Lumbar puncture and IO were performed with standard precautions versus an air purifying respirator (APR). A direct comparison was drawn for endotracheal intubation and bag-valve mask ventilation between 2 commonly used APRs. Success rate and number of attempts toward successful completion was recorded for all 4 procedures. Physicians filled out a postprocedure survey to assess their ease of use of the APR.

RESULTS

Twenty participants performed IO and LP using an APR and standard precautions. There was no statistical difference in the success rate, number of attempts, average time, or maintenance of sterility (LP only) for both procedures. Twenty total participants divided across 2 types of APR groups performed intubation and BMV. Success rate and number of attempts had no statistical difference for both procedures. Physician feedback surveys to assess the ease of use of APR compared with standard precautions had no statistically significant difference for all 4 procedures.

CONCLUSIONS

Wearing increased levels of PPE did not impact procedural success, length of time, sterility, number of attempts, or the physicians' ease in our study. Physicians should be encouraged to wear all appropriate PPE.

The Effect of a Plastic Barrier Drape on Resuscitation Performance and Provider Contamination: A Randomized Controlled Simulation-Based Pilot Trial

BACKGROUND

Patient barriers to protect health care workers from COVID-19 exposure have been studied for airway management. Few are tested for cardiopulmonary resuscitation (CPR). We sought to determine whether a plastic drape barrier affects resuscitation performance and contamination risks for a simulated cardiopulmonary arrest scenario.

METHODS

This pilot trial randomized in-hospital resuscitation teams of 4 to 6 participants to a plastic drape or without a drape in an in situ cardiopulmonary arrest simulation. The mannequin's airway emanated simulated virus particles (GloGerm, Moab, UT), detectable through UV light. Primary outcomes included airway management and CPR quality measures. Secondary outcomes included visible contamination on personal protective equipment (PPE). We used the Non-Technical Skills (NO-TECHS) instrument to measure perceived team performance and the NASA Task Load Index (NASA-TLX) to measure individual workload. Outcome variables were analyzed using an analysis of covariance (ANCOVA) with participant number as a covariate.

RESULTS

Seven teams were allocated to the intervention (plastic drape) group and 7 to the control. Intubation and ventilation performance (η 2 = 0.09, P > 0.3) and chest compression quality (η 2 = 0.03-0.19, P > 0.14) were not affected by the plastic drape. However, mean contaminated PPE per person decreased with the drape (2.8 ± 0.3 vs. 3.7 ± 0.3, partial η 2 = 0.29, P = 0.05). No differences in perceived workload nor team performance were noted ( P > 0.09).

CONCLUSIONS

In this pilot study, the use of a plastic drape barrier seems not to affect resuscitation performance on simulated cardiopulmonary arrest but decreases health care worker contamination risk. Further implementation trials could characterize the true risk reduction and any effect on resuscitation outcomes.

Effects of personal protective equipment on cardiopulmonary resuscitation quality and outcomes: A systematic review

Background

The impact of wearing personal protective equipment (PPE) during cardiopulmonary resuscitation (CPR) on CPR quality and patient outcomes is unclear. This systematic review aimed to examine whether wearing PPE during resuscitation affects patient outcomes, CPR quality and rescuer fatigue.

Methods

In this review registered in PROSPERO (CRD42022347746), we searched Medline, EMBASE and Cochrane library between 2000 and 2022. The inclusion criteria were studies: in actual or simulated cardiac arrest; comparing PPE with no PPE; and randomised controlled trials and observational studies with a English abstract. Risk of bias was assessed using Cochrane's Risk of Bias-2 and ROBINS-I tools and outcomes assessed with GRADE. We conducted a meta-analysis according to the study design. Quantitative data synthesis was done using a random-effect model incorporating the potential heterogeneity.

Results

A total of 17 simulation-based studies and 1 clinical study were included. All outcomes were judged to be very low certainty of evidence, subject to high risk of bias. The clinical study showed no difference in survival comparing enhanced and conventional PPE. Meta-analysis of 11 RCTs and 6 observational studies found no difference in CPR quality in rescuers wearing PPE compared with no PPE. Pooled rescuer fatigue was significantly worse in the PPE group (mean difference, 2.7 VAS score out of 10; 95% CI, 1.4-4.0).

Conclusions

PPE was not associated with reduced CPR quality or lower cardiac arrest survival. Rescuers wearing PPE may report more fatigue. This finding was mainly derived from simulation studies, additional clinical studies are needed.

Does the fit of personal protective equipment affect functional performance? A systematic review across occupational domains

OBJECTIVE

To explore the effect of personal protective equipment (PPE) fit on functional performance across a range of occupational domains.

BACKGROUND

PPE introduces an ergonomic, human systems integration, and mass burden to the wearer, and these factors are thought to be amplified if PPE is ill-fitting. However, few studies have considered the role of fit (static, dynamic, and cognitive) when evaluating PPE-related performance detriments in occupational settings.

METHOD

A systematic literature review was conducted to identify relevant studies, which were then critically appraised based on methodological quality and collated to compare key findings and present evidence-based recommendations for future research directions across a range of occupational domains.

RESULTS

16 published studies met the inclusion criteria, 88% of which found that the fit of PPE had a statistically significant effect on occupational performance. Poorly sized PPE resulted in slower or increased reaction time; decreased range of motion or mobility; decreased endurance or tolerance; decreased pulmonary function; and altered muscle activation. Limited research met the inclusion criteria and those that did had risks of bias in methodology quality.

CONCLUSION

Future research evaluating the effect of PPE on performance in occupational settings should aim to recruit a more representative population; consider sex as a covariate; quantify and evaluate PPE fit and performance when integrated with all relevant equipment items; include outcome measures related to all three categories of fit (static, dynamic, cognitive); and assess performance of operationally relevant tasks.

Exploring Nurses’ Perceptions of their Workload at Coronavirus Disease 2019 Isolation Ward in Jakarta, Indonesia: A Qualitative Study

BACKGROUND: Nurses are at the frontline of providing care to patients with COVID-19 and have the greatest potential to be affected by the COVID-19 pandemic. The high number of patients affected by COVID-19 causes an increasing burden on nurses caring for their patients; this has an impact on patient safety. Besides that, many other factors increase the workload of nurses. AIM: The purpose of this study is explore the workload of nurses, including perceptions and influencing factors.. METHODS: Nine nurses taking care of patients with COVID-19 are selected using purposive sampling at a hospital in Jakarta, Indonesia. Data was collected through semi-structured interview conducted online. Data saturation was achieved after interviewing nine nurses who work at COVID-19 isolation ward. This study adopts the constant comparison analysis developed by Glasser and Strauss. RESULTS: The paper resulted in eigh categories and four main themes, including distribution of workload, workload increase factors, challenges, and expectations of nurses caring for COVID-19 patients. CONCLUTION: The findings suggest that leaders and managers need to make policies that are fair to nurses so that they do not burden nurses with non-nursing care. They must also provide sufficient training for new nurses who will be assigned to the COVID-19 isolation ward.  

Resuscitation of Drowned Persons During the COVID-19 Pandemic: A Consensus Statement

IMPORTANCE

Resuscitation is a niche example of how the COVID-19 pandemic has affected society in the long term. Those trained in cardiopulmonary resuscitation (CPR) face the dilemma that attempting to save a life may result in their own harm. This is most of all a problem for drowning, where hypoxia is the cause of cardiac arrest and ventilation is the essential first step in reversing the situation.

OBJECTIVE

To develop recommendations for water rescue organizations in providing their rescuers with safe drowning resuscitation procedures during the COVID-19 pandemic.

EVIDENCE REVIEW

Two consecutive modified Delphi procedures involving 56 participants from 17 countries with expertise in drowning prevention research, resuscitation, and programming were performed from March 28, 2020, to March 29, 2021. In parallel, PubMed and Google Scholar were searched to identify new emerging evidence relevant to each core element, acknowledge previous studies relevant in the new context, and identify knowledge gaps.

FINDINGS

Seven core elements, each with their own specific recommendations, were identified in the initial consensus procedure and were grouped into 4 categories: (1) prevention and mitigation of the risks of becoming infected, (2) resuscitation of drowned persons during the COVID-19 pandemic, (3) organizational responsibilities, and (4) organizations unable to meet the recommended guidelines. The common measures of infection risk mitigation, personal protective equipment, and vaccination are the base of the recommendations. Measures to increase drowning prevention efforts reduce the root cause of the dilemma. Additional infection risk mitigation measures include screening all people entering aquatic facilities, defining criteria for futile resuscitation, and avoiding contact with drowned persons by rescuers with a high-risk profile. Ventilation techniques must balance required skill level, oxygen delivery, infection risk, and costs of equipment and training. Bag-mask ventilation with a high-efficiency particulate air filter by 2 trained rescuers is advised. Major implications for the methods, facilities, and environment of CPR training have been identified, including nonpractical skills to avoid being infected or to infect others. Most of all, the organization is responsible for informing their members about the impact of the COVID-19 pandemic and taking measures that maximize rescuer safety. Research is urgently needed to better understand, develop, and implement strategies to reduce infection transmission during drowning resuscitation.

CONCLUSIONS AND RELEVANCE

This consensus document provides an overview of recommendations for water rescue organizations to improve the safety of their rescuers during the COVID-19 pandemic and balances the competing interests between a potentially lifesaving intervention and risk to the rescuer. The consensus-based recommendations can also serve as an example for other volunteer organizations and altruistic laypeople who may provide resuscitation.

The effect of personal protective equipment on cardiac compression quality

Introduction

Cardiac compression is a cumbersome procedure. The American Heart Association suggests switching of cardiopulmonary resuscitation (CPR) provider every 2 min to prevent any decrease in resuscitation quality. High quality CPR is associated with improved outcomes. Previous studies have highlighted the difficulties in providing high quality CPR particularly while wearing personal protective equipment (PPE). This study aimed to evaluate the impact of personal protective equipment (PPE) use on CPR quality in prehospital cardiac arrest situations.

Methods

In this prospective simulation study, we compared the cardiac compression qualities and fatigue rates among prehospital health care professionals (HCPs) who were or were not using PPE.

Results

A total of 76 prehospital HCPs comprising 38 compression teams participated in this study. The mean compression rate was 117.71 ± 8.27/min without PPE and 115.58 ± 9.02/min with PPE (p = 0.191). Overall compression score was 86.95 ± 4.39 without PPE and 61.89 ± 14.43 with PPE (p < 0.001). Post-cardiac compression fatigue score was 4.42 ± 0.5 among HCPs who used their standard uniform and 7.74 ± 0.92 among those who used PPE (p < 0.001). The overall compression score difference between the two conditions was 25.05 ± 11.74 and the fatigue score difference was 3.31 ± 0.98.

Discussion

PPE use is associated with decreased cardiac compression quality and significantly higher fatigue rates than those associated with the use of standard uniforms. Routine use of mechanical compression devices should be considered when PPE is required for out-of-cardiac arrests.

Life-Saving Procedures Performed While Wearing CBRNe Personal Protective Equipment: A Mannequin Randomized Trial

INTRODUCTION

Chemical-biological-radiological-nuclear-explosive (CBRNe) are complex events. Decontamination is mandatory to avoid harm and contain hazardous materials, but can delay care. Therefore, the stabilization of patients in the warm zone seems reasonable, but research is limited. Moreover, subjects involved in biological events are considered infectious even after decontamination and need to be managed while wearing personal protective equipment (PPE), as seen with Ebola and COVID-19 pandemic. With this simulation mannequin trial, we assessed the impact of CBRNe PPE on cardiopulmonary resuscitation and combat casualty care procedures.

METHODS

We compared procedures performed by emergency medicine and anesthesiology senior residents, randomized in 2 groups (CBRNe PPE vs. no PPE). Chest compression (CC) depth was defined as the primary outcome. Time to completion was calculated for the following: tourniquet application; tension pneumothorax needle decompression; peripheral venous access (PVA) and intraosseous access positioning; and drug preparation and administration. A questionnaire was delivered to evaluate participants' perception.

RESULTS

Thirty-six residents participated. No significant difference between the groups in CC depth (mean difference = 0.26 cm [95% confidence interval = -0.26 to 0.77 cm, P = 0.318]), as well as for CC rate, CC complete release, and time for drugs preparation and administration was detected. The PPE contributed to significantly higher times for tourniquet application, tension pneumothorax decompression, peripheral venous access, and intraosseous access positioning. The residents found simulation relevant to the residencies' core curriculum.

CONCLUSIONS

This study suggests that cardiopulmonary resuscitation can be performed while wearing PPE without impacting quality, whereas other tasks requiring higher dexterity can be significantly impaired by PPE.Trial Registration Number: NCT04367454, April 29, 2020 (retrospectively registered).

Efficacy of cardiopulmonary resuscitation performance while wearing a powered air-purifying respirator

BACKGROUND

The use of personal protective equipment for respiratory infection control during cardiopulmonary resuscitation (CPR) is a physical burden to healthcare providers. The duration for which CPR quality according to recommended guidelines can be maintained under these circumstances is important. We investigated whether a 2-min shift was appropriate for chest compression and determined the duration for which chest compression was maintained in accordance with the recommended guidelines while wearing personal protective equipment.

METHODS

This prospective crossover simulation study was performed at a single center from September 2020 to October 2020. Five indicators of CPR quality were measured during the first and second sessions of the study period. All participants wore a Level D powered air-purifying respirator (PAPR), and the experiment was conducted using a Resusci Anne manikin, which can measure the quality of chest compressions. Each participant conducted two sessions. In Session 1, the sequence of 2 min of chest compressions, followed by a 2-min rest, was repeated twice; in Session 2, the sequence of 1-min chest compressions followed by a 1-min rest was repeated four times.

RESULTS

All 34 participants completed the study. The sufficiently deep compression rate was 65.9 ± 31.1% in the 1-min shift group and 61.5 ± 30.5% in the 2-min shift group. The mean compression depth was 52.8 ± 4.3 mm in the 1-min shift group and 51.0 ± 6.1 mm in the 2-min shift group. These two parameters were significantly different between the two groups. There was no significant difference in the other values related to CPR quality.

CONCLUSIONS

Our findings indicated that 1 min of chest compressions with a 1-min rest maintained a better quality of CPR while wearing a PAPR.

Analysis of Physiological Response during Cardiopulmonary Resuscitation with Personal Protective Equipment: A Randomized Crossover Study

The use of personal protective equipment (PPE) is required for the self-protection of healthcare workers during cardiopulmonary resuscitation (CPR) in patients at risk of aerosol transmission of infectious agents. The aim of this study was to analyze the impact of personal protective equipment on physiological parameters during CPR. A randomized, quasi-experimental, crossover design was used. The study was carried out in a training and simulation emergency box and the total sample consisted of 20 healthcare professionals. Two CPR tests were compared with the recommended sequence of 30 chest compressions and 2 ventilations. The duration of each test was 20 min. One of the CPR tests was carried out without using any PPE (CPR_control), i.e., performed with the usual clothing of each rescuer. The other test was carried out using a CPR test with PPE (i.e., CPR_PPE). The main variables of interest were: CPR quality, compressions, ventilations, maximum heart rate, body fluid loss, body temperature, perceived exertion index, comfort, thermal sensation and sweating. The quality of the CPR was similar in both tests. The maximum heart rate was higher in the active intervals (compressions + bag-valve-mask) of the test with PPE. CPR_PPE meant an increase in the perceived effort, temperature at the start of the thermal sensation test, thermal comfort and sweating, as opposed to CPR performed with usual clothing. Performing prolonged resuscitation with PPE did not influence CPR quality, but caused significant physiological demands. Rescuers were more fatigued, sweated more and their thermal comfort was worse. These results suggest that physical preparation should be taken into account when using PPE and protocols for physiological recovery after use should also be established.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Impact of personal protective equipment on the effectiveness of chest compression - A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

To assess the impact of personal protective equipment (PPE) on different aspects of chest compression (CC) during cardiopulmonary resuscitation, we conducted this study.

METHODS

This systematic review was performed according to the PRISMA. We searched PubMed, EMBASE and Web of Science from inception to June-6, 2020, limiting to the studies that reported the comparison of the effectiveness of CC in terms of CC rate, CC depth, the proportion of adequate CC rate, the proportion of adequate CC depth or proportion of adequate recoil; in study arms with or without PPE. Risk of bias was assessed by the ROB-2 and ROBINS-I tool. Quantitative data synthesis was done using the generic inverse variance method and the fixed-effects model.

RESULTS

Five simulation-based studies were finally included. A Significant decrease in CC rate (SMD: -0.28, 95%CI: -0.47 to -0.10) and CC depth (SMD: -0.26, 95%CI: -0.44 to -0.07) were observed in the PPE arm as compared to the no-PPE arm. The difference in CC rate was more prominently seen in adult CPR than in paediatric CPR. Without PPE, the proportion of adequate CC rate delivered was 0.74, which reduced significantly to 0.60 after use of PPE (p - 0.035). Similarly, the proportion of adequate CC depth was significantly lesser (p - 0.001) in PPE arm (0.55), as compared to that of the no-PPE arm (0.78).

CONCLUSION

The use of PPE compromises the quality of CC during CPR significantly, and newer ways to deliver chest compression has to be investigated. This study was prospectively registered in PROSPERO (CRD42020192031).

The Effect of Different Personal Protective Equipment Masks on Health Care Workers' Cardiopulmonary Resuscitation Performance During the Covid-19 Pandemic

Background

Personal protective equipment (PPE) is equipment that protects health care workers from harmful agents and organisms. The importance of this equipment was noticed again with the Coronavirus Disease 2019 (COVID-19) pandemic.

Objectives

In this study, we investigated the effect of different masks used as PPE on resuscitation quality and rescuer fatigue.

Methods

Participants applied chest compression without a mask, with a surgical mask, a filtering face-piece respirator (FFR) mask, and a half-face mask with active P3 filter. A smart watch was worn on the left wrists of the participants during chest compression in each condition. They were requested to rate their fatigue on a visual analogue scale.

Results

Statistically higher average pulse rates were found in the FFR mask and half-face mask conditions. FFR mask and half-face mask resulted in statistically worse results than surgical mask and no-mask conditions in the number of compressions per minute, compression depth, and compression effectiveness. Further, half-face mask and FFR mask caused more fatigue in participants.

Conclusion

Protective masks other than surgical masks used as PPE increase rescuer fatigue in CPR and negatively affect the quality of chest compressions.