Responding to the real problem of sustainable resuscitation skills with real assessment. Mixed-methods evaluation of an authentic assessment programme

INTRODUCTION

The retention of resuscitation skills is a widespread concern, with a rapid decay in competence frequently following training. Meanwhile, training programmes continue to be disconnected with real-world expectations and assessment designs remain in conflict with the evidence for sustainable learning. This study aimed to evaluate a programmatic assessment pedagogy which employed entrustment decision and the principles of authentic and sustainable assessment (SA).

METHODS

We conducted a prospective sequential explanatory mixed methods study to understand and address the sustainable learning challenges faced by final-year undergraduate paramedic students. We introduced a programme of five authentic assessments based on actual resuscitation cases, each integrating contextual elements that featured in these real-life events. The student-tutor consensus assessment (STCA) tool was configured to accommodate an entrustment scale framework. Each test produced dual student led and assessor scores. Students and assessors were surveyed about their experiences with the assessment methodologies and asked to evaluate the programme using the Ottawa Good Assessment Criteria.

RESULTS

Eighty-four students participated in five assessments, generating dual assessor-only and student-led results. There was a reported mean score increase of 9% across the five tests and an 18% reduction in borderline or below scores. No statistical significance was observed among the scores from eight assessors across 420 unique tests. The mean student consensus remained above 91% in all 420 tests. Both student and assessor participant groups expressed broad agreement that the Ottawa criteria were well-represented in the design, and they shared their preference for the authentic methodology over traditional approaches.

CONCLUSION

In addition to confirming local sustainability issues, this study has highlighted the validity concerns that exist with conventional resuscitation training designs. We have successfully demonstrated an alternative pedagogy which responds to these concerns, and which embodies the principles of SA, quality in assessment practice, and the real-world expectations of professionals.

Assessment of preparedness and proficiency in basic and advanced life support among nursing professionals: a cross-sectional study

Background

Cardiac diseases are among the leading causes of death worldwide, including sudden cardiac arrest in particular. Nursing professionals are often the first to encounter these scenarios in various settings. Adequate preparation and competent knowledge among nurses significantly impact survival rates positively.

Aim

To describe the state of knowledge about Basic and Advanced Life Support guidelines among Ecuadorian nursing professionals.

Methodology

A nationwide, descriptive, cross-sectional study was conducted from February to April 2023 among Ecuadorian nursing professionals. Participants were invited through official social media groups such as WhatsApp and Facebook. The study utilized a self-administered online questionnaire to evaluate theoretical knowledge of Basic Life Support (BLS) and Advanced Life Support (ALS). Knowledge scores were assigned based on the number of correct answers on the tests. T-tests and one-way ANOVA were used to examine relationships between knowledge scores and demographic and academic training variables.

Results

A total of 217 nursing professionals participated in the study. The majority of the participants were female (77.4%) and held a university degree (79.9%). Among them, only 44.7% claimed to have obtained a BLS training certificate at least once, and 19.4% had ALS certification. The overall BLS knowledge score (4.8/10 ± 1.8 points) was higher than the ALS score (4.3/10 ± 1.8 points). Participants who had obtained BLS certification and those who used evidence-based summaries as a source of extracurricular training achieved higher BLS and ALS knowledge scores.

Conclusion

Ecuadorian nursing professionals in this study exhibited a significant deficiency in theoretical knowledge of BLS and ALS. Formal training and preparation positively impact life support knowledge. Support and inclusion of Ecuadorian nurses in training and academic preparation programs beginning at the undergraduate level are essential for promoting life support knowledge and improving outcomes.

Hemodynamic Effect of Repeated Epinephrine Doses Decreases With Cardiopulmonary Resuscitation Cycle Progression

BACKGROUND

Epinephrine is administered to increase coronary perfusion pressure during advanced life support and promote short-term survival. Recent cardiopulmonary resuscitation (CPR) guidelines recommend an epinephrine dosing interval of 3 to 5 minutes during resuscitation; however, scientific evidence supporting this recommendation is lacking. Therefore, we aimed to investigate the hemodynamic effects of repeated epinephrine doses during CPR by monitoring augmented blood pressure after its administration in a swine model of cardiac arrest.

METHODS AND RESULTS

A secondary analysis of data from a published study was performed using a swine cardiac arrest model. The epinephrine dose was fixed at 1 mg, and the first dose of epinephrine was administered after no-flow and low-flow times of 2 minutes and 8 minutes, respectively, and subsequently administered every 4 minutes. Four cycles of dosing intervals were defined because a previous study was terminated 26 minutes after the induction of ventricular fibrillation. Augmented blood pressures and corresponding timelines were determined. Augmented blood pressure trends following cycles and the epinephrine effect duration were also monitored. Among the 140 CPR cycles, the augmented blood pressure after epinephrine administration was the highest during the first cycle of CPR and decreased gradually with further cycle repetitions. The epinephrine effect duration did not differ between repeated cycles. The maximum blood pressure was achieved 78 to 97 seconds after epinephrine administration.

CONCLUSIONS

Hemodynamic augmentation with repeated epinephrine administration during CPR decreased with cycle progression. Further studies are required to develop an epinephrine administration strategy to maintain its hemodynamic effects during prolonged resuscitation.

Pressure ulcers after prone positioning in patients undergoing extracorporeal membrane oxygenation: A cross-sectional study

BACKGROUND

The combination of prone positioning and extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome (ARDS) is recognized as safe but its use has been limited due to potential complications.

AIM

To report the prevalence of pressure ulcers and other complications due to prone positioning in adult patients receiving veno-venous ECMO.

STUDY DESIGN

This cross-sectional study was conducted in a tertiary level intensive care unit (ICU) in Milan (Italy), between January 2015 and December 2019. The study population was critically ill adult patients undergoing veno-venous ECMO. Statistical association between pressure ulcers and the type of body positioning (prone versus supine) was explored fitting a logistic model.

RESULTS

In the study period, 114 patients were treated with veno-venous ECMO and 62 (54.4%) patients were placed prone for a total of 130 prone position cycles. ECMO cannulation was performed via femoro-femoral configuration in the majority of patients (82.4%, 94/114). Pressure ulcers developed in 57.0% of patients (95%CI: 44.0%-72.6%), most often arising on the face and the chin (37.1%, 23/62), particularly in those placed prone. The main reason of prone positioning interruption was the decrease of ECMO blood flow (8.1%, 5/62). The fitted model showed no association between body position during ECMO and occurrence of pressure ulcers (OR 1.3, 95%CI: 0.5-3.6, p = .532).

CONCLUSIONS

Facial pressure ulcers were the most frequent complications of prone positioning. Nurses should plan and implement evidence-based care to prevent such pressure injuries in patients undergoing ECMO.

RELEVANCE TO CLINICAL PRACTICE

The combination of prone positioning and ECMO shows few life-threating complications. This manoeuvre during ECMO is feasible and safe when performed by experienced ICU staff.

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.

[The novelties of adult advanced life support and post-resuscitation therapy]

The fourth element of chain-of-survival contains advanced life support and post-resuscitation treatment. Both treatment options influence the outcome of patients suffering cardiac arrest. Advanced life support includes all interventions that require special medical equipment and expertise. High-quality chest compressions and early defibrillation (if indicated) compose the main elements of advanced life support. Clarifying and treating the cause of cardiac arrest have also high priority, in which point-of-care ultrasound plays an important role. In addition, securing higher level of airway and capnography, securing intravenous or intraosseous line, and the parenteral administration of drugs - such as epinephrine or amiodarone - are the most important steps of advanced life support. If conventional therapy is unsuccessful, extracorporeal circulatory support can be used in special patient populations. The protection of vital organs that are sensitive to hypoxia (brain and heart) has a high priority after the return of spontaneous circulation beside the causative treatment of cardiac arrest. The most important parts of the supportive post-resuscitation treatment are: targeting normoxia, normocapnia, normotension, normoglycemia, and the application of target temperature management. Orv Hetil. 2023; 164(12): 454-462.

Effect of a Targeted Ambulance Treatment Quality Improvement Programme on Outcomes from Out-of-Hospital Cardiac Arrest: A Metropolitan Citywide Intervention Study

The performance of ambulance crew affects the quality of pre-hospital treatment, which is vital to the survival for out-of-hospital cardiac arrest (OHCA) patients, yet remains suboptimal in China. In this retrospective analysis study, we aimed to examine the effect of a citywide quality improvement programme on provision of prehospital advanced life support (ALS) by emergency medical service (EMS) system. EMS-treated adult OHCA patients after the implementation of the programme (1 January 2021 to 30 June 2022) were compared with historical controls (1 June 2019 to 31 August 2020) in Suzhou. Multivariable logistic regression analysis and propensity score matching procedures were applied to compare the outcomes between two periods for total OHCA cases and subgroup of cases treated by fixed or non-fixed ambulance crews. A total of 1465 patients (pre-period/post-period: 610/855) were included. In the 1:1 matched analysis of 591 cases for each period, significant improvement (p < 0.05) was observed for the proportion of intravenous (IV) access (23.4% vs. 68.2%), advanced airway management (49.2% vs. 57.0%), and return of spontaneous circulation (ROSC) at handover (5.4% vs. 9.0%). The fixed ambulance crews performed better than non-fixed group in IV access and advanced airway management for both periods. There were significant increases in IV access (AOR 12.66, 95%CI 9.02−18.10, p < 0.001), advanced airway management (AOR 1.67, 95% CI 1.30−2.16, p < 0.001) and ROSC at handover (AOR 2.37, 95%CI 1.38−4.23, p = 0.002) after intervention in unfixed group, while no significant improvement was observed in fixed group except for IV access (AOR 7.65, 95%CI 9.02−18.10, p < 0.001). In conclusion, the quality improvement program was positively associated with the provision of prehospital ALS interventions and prehospital ROSC following OHCA. The fixed ambulance crews performed better in critical care provision and prehospital outcome, yet increased protocol adherence and targeted training could fill the underperformance of non-fixed crews efficaciously.

2022 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

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

simulated teams

Aim

Effective team leadership is essential during cardiopulmonary resuscitation (CPR) and is taught during international advanced life support (ALS) courses. This study compared the judgement of team leadership during summative assessments after those courses using different validated assessment tools while comparing two different summative assessment methods.

Methods

After ALS courses, twenty videos of simulated team assessments and 20 videos of real team assessments were evaluated and compared. Simulated team assessment used an instructor miming a whole team, whereas real team assessment used course participants as a team that acted on the team leader's commands. Three examiners individually evaluated each video on four different validated team leadership assessment tools and on the original European Resuscitation Council's (ERC) scenario test assessment form which does not assess leadership. The primary outcome was the average performance summary score between all three examiners for each assessment method.

Results

The average performance summary score for each of the four assessment tools was significantly higher for real team assessments compared to simulated team assessments (all p-values < 0.01). The summary score of the ERC's scenario test assessment form was comparable between both assessment methods (p = 0.569), meaning that participants of both assessments performed equally.

Conclusion

Team leadership performance is rated significantly higher in real team summative assessments after ALS courses compared to simulated team assessments by four leadership assessment tools but not by the standard ERC's scenario test assessment form. These results suggest that summative assessments in ALS courses should integrate real team assessments, and a new assessment tool including an assessment of leadership skills needs to be developed.

Outcome differences between PARAMEDIC2 and the German Resuscitation Registry: a secondary analysis of a randomized controlled trial compared with registry data

BACKGROUND AND IMPORTANCE

There has been much discussion of the results of the PARAMEDIC2 trial, as resuscitation outcome rates are considerably lower in this trial than in country-level registries on out-of-hospital cardiac arrest (OHCA). Here, we developed a statistical framework to investigate this gap and to examine possible sources for observed discrepancies in outcome rates.

DESIGN

Summary data from the PARAMEDIC2 trial were used as available in the publication of this study. We developed a modelling framework based on logistic regression to compare data from this randomized controlled trial and registry data from the German Resuscitation Registry (GRR), where we considered 26 019 patients treated with epinephrine for OHCA in the GRR. To account and adjust for differences in patient characteristics and baseline variables predictive for outcomes after OHCA between the GRR cohort and the PARAMEDIC2 study sample, we included all available variables determined at the arrival of EMS personnel in the modelling framework: age, sex, initial cardiac rhythm, cause of cardiac arrest, witness of cardiac arrest, CPR performed by a bystander, and the interval between emergency call and arrival of the ambulance at the scene (baseline model). In order to find possible explanations for the discrepancies in outcome between PARAMEDIC2 and GRR, in a second (baseline plus treatment) model, we additionally included all available variables related to the interventions of the EMS personnel (type of airway management, type of vascular access, and time to administration of epinephrine).

MAIN RESULTS

A patient cohort with baseline variables as in the PARAMEDIC2 trial would have survived to hospital discharge in 7.7% and survived with favourable neurological outcome in 5.0% in an EMS and health care system as in Germany, compared with 3.2 and 2.2%, respectively, in the Epinephrine group of the trial. Adding treatment-related variables to our logistic regression model, the rate of survival to discharge would decrease from 7.7 (for baseline variables only) to 5.6% and the rate of survival with favourable neurological outcome from 5.0 to 3.4%.

CONCLUSION

Our framework helps in the medical interpretation of the PARAMEDIC2 trial and the transferability of the trial's results for other EMS systems. Significantly higher rates of survival and favourable neurological outcome than reported in this trial could be possible in other EMS and health care systems.

2022 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

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Tracheal Intubation during Advanced Life Support Using Direct Laryngoscopy versus Glidescope(®) Videolaryngoscopy by Clinicians with Limited Intubation Experience: A Systematic Review and Meta-Analysis

The use of the Glidescope® videolaryngoscope might improve tracheal intubation performance in clinicians with limited intubation experience, especially during cardiopulmonary resuscitation (CPR). The objective of this systematic review and meta-analysis is to compare direct laryngoscopy to Glidescope® videolaryngoscopy by these clinicians. PubMed/Medline and Embase were searched from their inception to 7 July 2020 for randomized controlled trials, including simulation studies. Studies on adult patients or adult-sized manikins were included when direct laryngoscopy was compared to Glidescope® videolaryngoscopy by clinicians with limited experience in tracheal intubation (<10 intubations per year). The primary outcome was the intubation first-pass success rate. Secondary outcomes were time to successful intubation and chest compression interruption duration during intubation. The risk of bias was assessed with the Cochrane risk of bias tool. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). We included 4 clinical trials with 525 patients and 20 manikin trials with 2547 intubations. Meta-analyses favored Glidescope® videolaryngoscopy over direct laryngoscopy regarding first-pass success (clinical trials: risk ratio [RR] = 1.61; 95% confidence interval [CI]: 1.16−2.23; manikin trials: RR = 1.17; 95% CI: 1.09−1.25). Clinical trials showed a shorter time to achieve successful intubation when using the Glidescope® (mean difference = 17.04 s; 95% CI: 8.51−25.57 s). Chest compression interruption duration was decreased when using the Glidescope® videolaryngoscope. The certainty of evidence ranged from very low to moderate. When clinicians with limited intubation experience have to perform tracheal intubation during advanced life support, the use of the Glidescope® videolaryngoscope improves intubation and CPR performance compared to direct laryngoscopy.

Instructor Development Workshops for Advanced Life Support Training Courses Held in a Fully Virtual Space: Observational Study

Background

Various face-to-face training opportunities have been lost due to the COVID-19 pandemic. Instructor development workshops for advanced resuscitation (ie, advanced life support) training courses are no exception. Virtual reality (VR) is an attractive strategy for remote training. However, to our knowledge, there are no reports of resuscitation instructor training programs being held in a virtual space.

Objective

This study aimed to investigate the learning effects of an instructor development workshop that was conducted in a virtual space.

Methods

In this observational study, we created a virtual workshop space by using NEUTRANS (Synamon Inc)—a commercial VR collaboration service. The instructor development workshop for the advanced life support training course was held in a virtual space (ie, termed the VR course) as a certified workshop by the Japanese Association of Acute Medicine. We asked 13 instructor candidates (students) who participated in the VR course to provide a workshop report (VR group). Reports from a previously held face-to-face workshop (ie, the face-to-face course and group) were likewise prepared for comparison. A total of 5 certified instructor trainers viewed and scored the reports on a 5-point Likert scale.

Results

All students completed the VR course without any problems and received certificates of completion. The scores for the VR group and the face-to-face group did not differ at the level of statistical significance (median 3.8, IQR 3.8-4.0 and median 4.2, IQR 3.9-4.2, respectively; P=.41).

Conclusions

We successfully conducted an instructor development workshop in a virtual space. The degree of learning in the virtual workshop was the same as that in the face-to-face workshop.

Randomized controlled trial comparing pit crew resuscitation model against standard advanced life support training

Objectives

Pit crew models are designed to improve teamwork in critical medical situations, like advanced life support (ALS). We investigated if a pit crew model training improves performance assessment and ALS skills retention when compared to standard ALS education.

Methods

This was a prospective, blinded, randomized, and controlled, parallel-group trial. We recruited students to 4-person resuscitation teams. We video recorded simulated ALS-situations after the ALS education and after 6-month follow-up. We analyzed technical skills (TS) and non-technical skills (NTS) demonstrated in them with an instrument measuring TS and NTS, and used a linear mixed model to model the difference between the groups in the TS and NTS. Another linear model was used to explore the difference between the groups in hands-on ratio and hands-free time. The difference in the total assessment score was analyzed with the Mann-Whitney U-test. The primary outcome was the difference in the total assessment score between the groups at follow-up. ALS skills were considered to be a secondary outcome.

Results

Twenty-six teams underwent randomization. Twenty-two teams received the allocated education. Fifteen teams were evaluated at 6-month follow-up: 7 in the intervention group and 8 in the control group. At 6-month follow-up, the median (Q1-Q3) total assessment score for the control group was 6.5 (6-8) and 7 (6.25-8) for the intervention group but the difference was not significant (U = 133, P = 0.373). The intervention group performed better in terms of chest compression quality (interaction term, β3 = 0.23; 95% confidence interval, 0.01-0.50; P = 0.043) at follow-up.

Conclusion

We found no difference in overall performance between the study arms. However, trends indicate that the pit crew model may help to retain ALS skills in different areas like chest compression quality.

Out-of-hospital cardiac arrest in the Algarve region of Portugal: a retrospective registry trial with outcome data

BACKGROUND AND IMPORTANCE

Out-of-hospital cardiac arrest is a leading cause of death in Europe. An understanding of region-specific factors is essential for informing strategies to improve survival.

DESIGN

This retrospective observational study included all out-of-hospital cardiac arrest patients attended by the Emergency Medical Service of the Algarve in 2019. Outcome data were derived from hospital records.

MAIN RESULTS

In 2019, there were 850 out-of-hospital cardiac arrests treated with cardiopulmonary resuscitation in the Algarve, representing a population incidence of 189/100 000. Return of spontaneous circulation occurred in 83 patients (9.8%), of whom 17 (2.0%) had survival to hospital discharge and 15 (1.8%) had survival with good neurologic outcome. Among patients in the Utstein comparator group, survival to hospital discharge was 21.4%. Predictors of return of spontaneous circulation were age, witnessed arrest, initial shockable rhythm, time of year, time to cardiopulmonary resuscitation, and time to advanced life support. Predictors of survival to hospital discharge were age, initial shockable rhythm, time to rhythm analysis, and time to advanced life support. Predictors of survival with good neurologic outcome were age, initial shockable rhythm, and time to return of spontaneous circulation.

CONCLUSIONS

The incidence of out-of-hospital cardiac arrest with cardiopulmonary resuscitation in the Algarve was higher than in other jurisdictions while return of spontaneous circulation, survival to hospital discharge, and survival with good neurologic outcome were comparatively low. An aging population, a geographically diverse region, and a low incidence of bystander cardiopulmonary resuscitation may have contributed to these outcomes. These results confirm the importance of early cardiopulmonary resuscitation, early rhythm assessment, and early advanced life support, all of which are potentially modifiable through public education, broadening of the defibrillator network and increased availability of advanced life support teams.

Advanced Life Support for out-of-hospital Chest Pain: The Opals Study

Context: As many as 14% of patients transported by ambulance with chest pain die prior to hospital discharge. To date, no high-quality controlled trials have revealed that prehospital advanced life support interventions affect survival for these patients.Objective: The Ontario Prehospital Advanced Life Support (OPALS) Study assessed the effect of adding an advance life support service to an existing basic life support emergency medical service program, on the rate of mortality and morbidity for patients with out-of-hospital chest pain.Design: Controlled clinical trial comparing survival for 9 months before and 9 after instituting an advanced life support program.Setting: Thirteen urban and suburban Ontario communities (populations ranging from 30,000 to 750,000; total, 2.5 million).Patients: All adult patients with a primary complaint of chest pain and transported by paramedics to the emergency department.Intervention: Paramedics were trained in standard advanced life support, which includes endotracheal intubation, intravenous furosemide and morphine, oral ASA, and sublingual NTG. Emergency medical services within each community had to meet predefined criteria in order to qualify for the advanced life support phase.Main Outcome Measure: Survival to hospital discharge.Results: Overall, 12,168 patients were enrolled in either the basic life support phase (N = 5,788) or the advanced life support phase (N = 6,380). The rate of mortality significantly decreased from 4.3% in the basic life support phase to 3.2% in the advanced life support phase (absolute change 1.1, 95% CI 0.4-1.8, P = 0.0013). We also demonstrated a decrease in mortality for the subgroup of patients with a discharge diagnosis of myocardial infarction (13.1 percent vs 8.2 percent, P = 0.002).Conclusions: The addition of a prehospital advanced life support program to an existing basic life support emergency medical service was associated with a significant decrease in the mortality rate among patients complaining of chest pain. Future research should clarify the most effective interventions and target specific populations.ClinicalTrials.gov Identifier: NCT00212953.

Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest

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.

Epinephrine dosing interval and neurological outcome in out-of-hospital cardiac arrest

OBJECTIVE

Current guidelines for cardiopulmonary resuscitation (CPR) recommend that standard-dose epinephrine be administered every 3-5 minutes during cardiac arrest. However, there is a knowledge gap regarding the optimal epinephrine dosing interval. This study aimed to examine the association between epinephrine dosing intervals and outcomes after out-of-hospital cardiac arrest (OHCA).

METHODS

This was a nationwide population-based observational study using data from a Japanese government-led registry of OHCA, including patients who experienced OHCA in Japan from 2011 to 2017. We defined the epinephrine dosing interval as the time interval between the first epinephrine administration and return of spontaneous circulation in the prehospital setting, divided by the total number of epinephrine doses. The primary outcome was 1-month neurologically favorable survival.

RESULTS

A total of 10,965 patients (mean (SD) age, 75.8 (14.3) years; 59.8% male) were included. The median epinephrine dosing interval was 3.5 minutes (IQR, 2.5-4.5; mean (SD), 3.6 (1.8)). Only approximately half of the patients received epinephrine administration with a standard dosing interval, as recommended in the current CPR guidelines. After multivariable adjustment, compared with the standard dosing interval, neither shorter nor longer epinephrine dosing intervals were associated with neurologically favorable survival after OHCA (Short vs Standard: adjusted OR 0.87 [95%CI 0.66-1.15]; and Long vs Standard: adjusted OR 1.08 [95%CI 0.76-1.55]). Similar associations were observed in propensity score-matched analyses.

CONCLUSIONS

The epinephrine dosing interval was not associated with 1-month neurologically favorable survival after OHCA. Our findings do not deny the recommended epinephrine dosing interval in the current CPR guidelines.

Feline cardiopulmonary resuscitation: Getting the most out of all nine lives

PRACTICAL RELEVANCE

Cardiopulmonary arrest (CPA) can occur in any veterinary or animal care setting and is a particular risk in scenarios involving ill, injured or anesthetized patients. Education of all staff on the prevention and recognition of CPA, as well as the performance of cardiopulmonary resuscitation (CPR), is vital to influencing outcome.

EVIDENCE BASE

While there is a plethora of information regarding CPA and CPR in human medicine, there are comparably few studies in the veterinary literature. Many of the current veterinary guidelines are extrapolated from human medicine or studies based on animal models. Ongoing work is needed to tailor guidelines and recommendations to our domestic feline (and canine) patients in a clinical setting.

AIM

The aim of this article, which is intended for veterinarians in all areas of small animal practice, is to provide an evidence-based review of CPA and CPR in feline patients. The authors have drawn heavily on detailed recommendations published by the Reassessment Campaign on Veterinary Resuscitation (RECOVER) initiative - one of the few resources specific to the veterinary clinical setting - as well as reviewing the available peer-reviewed literature studies, in constructing this article. Among the topics discussed are recognizing and preventing CPA, staff training and clinic preparedness, basic life support and advanced life support interventions, and appropriate post-cardiac arrest care.

Are You Prepared to Save a Life? Nursing Students' Experience in Advanced Life Support Practice

The objective of this study was to explore the experiences and perceptions of nursing students after applying advanced life support techniques on a hospitalised patient in cardiac arrest in a simulated setting. A qualitative descriptive phenomenological study was conducted. Fifty-four nursing students from the University of Almería (Spain) participated. Three main themes and six subthemes were identified, which illustrate the experiences and perceptions of nursing students about performing advanced life support. The main themes were: (1) Analysing practice as part of the learning process, with the subthemes “working in an unknown environment” and “acquiring knowledge as the key to success”; (2) Facing reality: nursing students’ perceptions of an emergency situation, with the subthemes “facing stressful elements” and “emotional impact in emergency situations”; (3) Experience as a key element to integrating advanced life support into the healthcare setting, with the subthemes “discovering and facing the experience as a team” and “linking and transferring the situation to a real clinical setting”. The nursing students reported that the process of practising for an emergency situation through simulation was a fundamental part of their training, as it allowed them to acquire skills necessary for emergency situations and improve their clinical performance in advanced life support. In addition, they considered the experience a key element in integrating advanced life support into the healthcare setting. The results of this study highlight the need to develop and implement training programs focused on clinical and teamwork skills in nursing programs.

Methodology of Specialist Physicians Training: From Traditional to e-Learning

Different studies show that mixed methodology can be effective in medical training. However, there are no conclusive studies in specialist training on advanced life support (ALS). The main objective of this research is to determine if, with mixed didactic methodology, which includes e-learning, similar results are produced to face-to-face training. The method used was quasi-experimental with a focus on efficiency and evaluation at seven months, in which 114 specialist doctors participated and where the analysis of the sociodemographic and pre-test variables points to the homogeneity of the groups. The intervention consisted of e-learning training plus face-to-face workshops versus standard. The results were the performance in knowledge and technical skills in cardiac arrest scenarios, the perceived quality, and the perception of the training. There were no significant differences in immediate or deferred performance. In the degree of satisfaction, a significant difference was obtained in favour of the face-to-face group. The perception in the training itself presented similar results. The main limitations consisted of sample volume, dropping out of the deferred tests, and not evaluating the transfer or the impact. Finally, mixed methodology including e-learning in ALS courses reduced the duration of the face-to-face sessions and allowed a similar performance.

Controlled automated reperfusion of the whole body after cardiac arrest

Background

Sudden circulatory arrest (CA) requiring cardiopulmonary resuscitation (CPR) has for decades been associated with high mortality and frequent neurological sequelae in the rarer survivors. The high mortality and morbidity are potentially related to a severe and global ischemia/reperfusion injury (IRI) of the whole body, especially the brain. Consequently, strategies to counteract this severe IRI may improve survival and neurological recovery of affected patients.

Methods

Based on the target to limit IRI in single organs, suitable parameters and methods were composed to form a global treatment concept, the CARL method (controlled automated reperfusion of the whole body). The concept centers on extracorporeal circulation, enhanced with readily available online monitoring. It allows for targeted adaption of different parameters (i.e., blood pressure and flow, temperature, oxygen content, electrolytes) during the reperfusion process, in the sense of a controlled reperfusion. Parameters and elements of the CARL method were extensively tested in a chronic animal model. An appropriate medical device, the system configuration "CIRD 1.0" (Controlled Integrated Resuscitation Device) is approved to be applied to patients.

Results

A set of parameters that support a limitation of a global IRI have been identified in over 250 animal experiments. Their specific targets and surveillance using adequate monitoring features are described. Using the CIRD in a single center, 14 patients with witnessed, but extremely prolonged CPR (51-120 minutes) have been treated with CARL. The outcome of these patients was favorable, with 7 of 14 patients regaining full consciousness and 6 of 7 allocated to Cerebral Performance Class (CPC) "1".

Conclusions

CA followed by CPR is associated with a very high mortality and frequent neurological sequelae. Limiting the occurring severe and global IRI may be a key to an improved survival and neurological recovery. Therefore, the therapeutic approach of CARL, which stands for a personalized, comprehensive therapy based on a readily available set of monitoring data and diagnostic findings, has been developed. First experience in patients indicates beneficial effects that call for further studies in the field of CARL.

Effects of advanced life support versus basic life support on the mortality rates of patients with trauma in prehospital settings: a study protocol for a systematic review and meta-analysis

INTRODUCTION

Advanced life support (ALS) is thought to be associated with improved survival in prehospital trauma care when compared with basic life support (BLS). However, evidence on the benefits of prehospital ALS for patients with trauma is controversial. Therefore, we aim to clarify if ALS improves mortality in patients with trauma when compared with BLS by conducting a systematic review and meta-analysis of the recent literature.

METHODS AND ANALYSIS

We will perform searches in PubMed, Embase and the Cochrane Central Register of Controlled Trials for published observational studies, controlled before-and-after studies, randomised controlled trials and other controlled trials conducted in humans and published until March 2017. We will screen search results, assess study selection, extract data and assess the risk of bias in duplicate; disagreements will be resolved through discussions. Data from clinically homogeneous studies will be pooled using a random-effects meta-analysis, heterogeneity of effects will be assessed using the χ² test of homogeneity, and any observed heterogeneity will be quantified using the I² statistic. Last, the Grading of Recommendations Assessment, Development and Evaluation approach will be used to rate the quality of the evidence.

ETHICS AND DISSEMINATION

Our study does not require ethical approval as it is based on findings of previously published articles. Results will be disseminated through publication in a peer-reviewed journal, presentations at relevant conferences and publications for patient information.

TRIAL REGISTRATION NUMBER

PROSPERO (International Prospective Register of Systematic Reviews) registration number CRD42017054389.

Similar long-term survival of consecutive in-hospital and out-of-hospital cardiac arrest patients treated with targeted temperature management

Objective

The long-term survival of in-hospital cardiac arrest (IHCA) patients treated with targeted temperature management (TTM) is poorly described. The aim of this study was to compare the outcomes of consecutive IHCA with out-of-hospital cardiac arrest (OHCA) patients treated with TTM.

Design, setting, and patients

Retrospectively collected data on all consecutive adult patients treated with TTM at a university tertiary heart center between 2005 and 2011 were analyzed.

Measurements

Primary endpoints were survival to hospital discharge and long-term survival. Secondary endpoint was neurological outcome assessed using the Pittsburgh cerebral performance category (CPC).

Results

A total of 282 patients were included in this study; 233 (83%) OHCA and 49 (17%) IHCA. The IHCA group presented more often with asystole, received bystander cardiopulmonary resuscitation (CPR) in all cases, and had shorter time to return of spontaneous circulation (ROSC). Survival to hospital discharge was 54% for OHCA and 53% for IHCA (adjusted odds ratio 0.98 [95% confidence interval {CI}; 0.43–2.24]). Age ≤60 years, bystander CPR, time to ROSC ≤10 min, and shockable rhythm at presentation were associated with survival to hospital discharge. Good neurologic outcome among survivors was achieved by 86% of OHCA and 92% of IHCA (P=0.83). After a median follow-up time of >5 years, 83% of OHCA and 77% of IHCA were alive (adjusted hazard ratio [HR] 1.51 [95% CI; 0.59–3.91]). Age ≤60 years was the only factor associated with long-term survival (adjusted HR 2.73 [95% CI; 1.36–5.52]).

Conclusion

There was no difference in short- and long-term survival and no difference in neurologic outcome to hospital discharge between IHCA and OHCA patients treated with TTM despite higher frequency of asystole in IHCA.

Assessment of long-term impact of formal certified cardiopulmonary resuscitation training program among nurses

CONTEXT

Cardiopulmonary resuscitation (CPR) and emergency cardiovascular care guidelines are periodically renewed and published by the American Heart Association. Formal training programs are conducted based on these guidelines. Despite widespread training CPR is often poorly performed. Hospital educators spend a significant amount of time and money in training health professionals and maintaining basic life support (BLS) and advanced cardiac life support (ACLS) skills among them. However, very little data are available in the literature highlighting the long-term impact of these training.

AIMS

To evaluate the impact of formal certified CPR training program on the knowledge and skill of CPR among nurses, to identify self-reported outcomes of attempted CPR and training needs of nurses.

SETTING AND DESIGN

Tertiary care hospital, Prospective, repeated-measures design.

SUBJECTS AND METHODS

A series of certified BLS and ACLS training programs were conducted during 2010 and 2011. Written and practical performance tests were done. Final testing was undertaken 3-4 years after training. The sample included all available, willing CPR certified nurses and experience matched CPR noncertified nurses.

STATISTICAL ANALYSIS USED

SPSS for Windows version 21.0.

RESULTS

The majority of the 206 nurses (93 CPR certified and 113 noncertified) were females. There was a statistically significant increase in mean knowledge level and overall performance before and after the formal certified CPR training program (P = 0.000). However, the mean knowledge scores were equivalent among the CPR certified and noncertified nurses, although the certified nurses scored a higher mean score (P = 0.140).

CONCLUSIONS

Formal certified CPR training program increases CPR knowledge and skill. However, significant long-term effects could not be found. There is a need for regular and periodic recertification.

Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether or not recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care, because the evidence suggests that either death or a poor outcome is inevitable.

Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

[Analysis of care in cardiorespiratory arrest in an emergency medical unit]

OBJECTIVE

To describe the epidemiological profile of cardiac arrests and to determine factors associated with successful cardiopulmonary resuscitation (CPR).

DESIGN

Retrospective descriptive observational study. SITES: Badajoz city (Spain) and population attended by the Medical Emergency Unit of the Public Health System in that city.

PARTICIPANTS

A study 359 cardiac arrests resuscitated between January 2002 and May 2009.

RESULTS

Out of the cardiac arrests that ocurred in adults, 65.40% were male, the cause was not traumatic in 88%; 65.70% occurred in the patient's home,and in 6% of the cases there had been basic life support. The higher success rate after was achieved in adult male patients (OR: 0,43; CI 95%; 0.25-0.73; P=.002), whose rhythm was shockable (OR: 0,16; CI 95%: 0,09-0,27; P<.001) and when the start time of advanced life support was equal to or less than 10 minutes (OR: 0,22; CI 95%: 0,10-0,49; P<.001). In a multivariant analysis success of CPR was independently associated with male gender, initial shockable rhythm, and the onset of advanced life support within 10 minutes. Nine children were revived, but success was not achieved in any.

CONCLUSIONS

Cardiac arrests are more common in adults and in few cases CPR is previously performed. Male gender, an initial shockable rhythm, and the early initiation of advanced life support, are associated with higher success of CPR. There were few CPR performed in cardiac arrest in children, and the prognosis was more unfavorable.

The Collaborative Pediatric Critical Care Research Network Critical Pertussis Study: collaborative research in pediatric critical care medicine

OBJECTIVE

To provide an updated overview of critical pertussis to the pediatric critical care community and describe a study of critical pertussis recently undertaken.

SETTING

The six sites, seven hospitals of the Collaborative Pediatric Critical Care Research Network, and 17 outside sites at academic medical centers with pediatric intensive care units.

RESULTS

Despite high coverage for childhood vaccination, pertussis causes substantial morbidity and mortality in US children, especially among infants. In pediatric intensive care units, Bordetella pertussis is a community-acquired pathogen associated with critical illness and death. The incidence of medical and developmental sequelae in critical pertussis survivors remains unknown, and the appropriate strategies for treatment and support remain unclear. The Collaborative Pediatric Critical Care Research Network Critical Pertussis Study has begun to evaluate critical pertussis in a prospective cohort.

CONCLUSION

Research is urgently needed to provide an evidence base that might optimize management for critical pertussis, a serious, disabling, and too often fatal illness for U.S. children and those in the developing world.