Part 8: Interdisciplinary topics

Moving from "Do Not Resuscitate" Orders to Standardized Resuscitation Plans and Shared-Decision Making in Hospital Inpatients

Not for Cardiopulmonary Resuscitation (No-CPR) orders, or the local equivalent, help prevent futile or unwanted cardiopulmonary resuscitation. The importance of unambiguous and readily available documentation at the time of arrest seems self-evident, as does the need to establish a patient’s treatment preferences prior to any clinical deterioration. Despite this, the frequency and quality of No-CPR orders remains highly variable, while discussions with the patient about their treatment preferences are undervalued, occur late in the disease process, or are overlooked entirely.

This review explores the evolution of hospital patient No-CPR/Do Not Resuscitate decisions over the past 60 years. A process based on standardized resuscitation plans has been shown to increase the frequency and clarity of documentation, reduce stigma attached to the documentation of a No-CPR order, and support the delivery of medically appropriate and desired care for the hospital patient.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Paediatric resuscitation training: is e-learning the answer? A before and after pilot study

AIM

To determine whether an e-learning resuscitation programme was able to improve the knowledge and competence of doctors and nurses in providing cardiopulmonary resuscitation to children in a simulated cardiac arrest.

METHOD

A prospective before and after pilot study comprising of a simulated paediatric resuscitation before and after participants undertook an e-learning programme. Participants were emergency department doctors and new graduate nurses from The Children's Hospital at Westmead, Australia. Primary outcome measures were the ability to perform successful basic life support (BLS) and advanced life support (ALS) according to published guidelines. Secondary outcome measures were the individual steps in performing the overall resuscitation and subjective feedback from participants.

RESULTS

Fifty-six clinicians were enrolled in the study (29 doctors and 27 nurses). Thirty-seven were re-tested (25 doctors and 12 nurses). The mean time between tests was 49 days (17 standard deviation). The e-learning module led to an improvement in participants' ability to perform BLS by 51% (P < 0.001) and ALS by 57% (P= 0.001) overall resulting in an overall competence of 89% (BLS) and 65% (ALS). There were also significant improvements in time to rhythm recognition (P= 0.006), time to first defibrillation (P= 0.009) and participants' self-reported knowledge and confidence in BLS and ALS (P < 0.001).

CONCLUSIONS

E-learning does improve both the knowledge and competence of doctors and nurses in providing cardiopulmonary resuscitation to children in the simulation environment.

Improving survival rate of patients with in-hospital cardiac arrest: five years of experience in a single center in Korea

The aim of this study was to describe the cause of the recent improvement in the outcomes of patients who experienced in-hospital cardiac arrest. We retrospectively analyzed the in-hospital arrest registry of a tertiary care university hospital in Korea between 2005 and 2009. Major changes to the in-hospital resuscitation policies occurred during the study period, which included the requirement of extensive education of basic life support and advanced cardiac life support, the reformation of cardiopulmonary resuscitation (CPR) team with trained physicians, and the activation of a medical emergency team. A total of 958 patients with in-hospital cardiac arrest were enrolled. A significant annual trend in in-hospital survival improvement (odds ratio = 0.77, 95% confidence interval 0.65-0.90) was observed in a multivariate model. The adjusted trend analysis of the return of spontaneous circulation, six-month survival, and survival with minimal neurologic impairment upon discharge and six-months afterward revealed similar results to the original analysis. These trends in outcome improvement throughout the study were apparent in non-ICU (Intensive Care Unit) areas. We report that the in-hospital survival of cardiac arrest patients gradually improved. Multidisciplinary hospital-based efforts that reinforce the Chain of Survival concept may have contributed to this improvement.

Safety and efficacy of defibrillator charging during ongoing chest compressions: a multi-center study

BACKGROUND

Pauses in chest compressions during cardiopulmonary resuscitation have been shown to correlate with poor outcomes. In an attempt to minimize these pauses, the American Heart Association recommends charging the defibrillator during chest compressions. While simulation work suggests decreased pause times using this technique, little is known about its use in clinical practice.

METHODS

We conducted a multi-center, retrospective study of defibrillator charging at three US academic teaching hospitals between April 2006 and April 2009. Data were abstracted from CPR-sensing defibrillator transcripts. Pre-shock pauses and total hands-off time preceding the defibrillation attempts were compared among techniques.

RESULTS

A total of 680 charge-cycles from 244 cardiac arrests were analyzed. The defibrillator was charged during ongoing chest compressions in 448 (65.9%) instances with wide variability across the three sites. Charging during compressions correlated with a decrease in median pre-shock pause [2.6s (IQR 1.9-3.8) vs 13.3s (IQR 8.6-19.5); p < 0.001] and total hands-off time in the 30s preceding defibrillation [10.3s (IQR 6.4-13.8) vs 14.8s (IQR 11.0-19.6); p < 0.001]. The improvement in hands-off time was most pronounced when rescuers charged the defibrillator in anticipation of the pause, prior to any rhythm analysis. There was no difference in inappropriate shocks when charging during chest compressions (20.0% vs 20.1%; p = 0.97) and there was only one instance noted of inadvertent shock administration during compressions, which went unnoticed by the compressor.

CONCLUSIONS

Charging during compressions is underutilized in clinical practice. The technique is associated with decreased hands-off time preceding defibrillation, with minimal risk to patients or rescuers.

[Ethics of the cardiopulmonary resuscitation decisions]

Cardiopulmonary Resuscitation (CPR) must be attempted if indicated, not done if it is not indicated or if the patient does not accept or has previously rejected it and withdrawn it if it is ineffective. If CPR is considered futile, a Do-Not-Resuscitate Order (DNR) will be recorded. This should be made known to all physicians and nurses involved in patient care. It may be appropriate to limit life-sustaining-treatments for patients with severe anoxic encephalopathy, if the possibility of clinical evolution to brain death is ruled out. After CPR it is necessary to inform and support families and then review the process in order to make future improvements. After limitation of vital support, certain type of non-heart-beating-organ donation can be proposed. In order to acquire CPR skills, it is necessary to practice with simulators and, sometimes, with recently deceased, always with the consent of the family. Research on CPR is essential and must be conducted according to ethical rules and legal frameworks.

[Glossary of bioethic terms and expressions frequently used in pediatric intensive care practice]

Ethical issues are of increasing interest in current medicine, and pediatrics is no exception. In critical care, the relevance of these considerations becomes even greater. Commonly used expressions in bioethics, frequently lead to terminological confusion and misunderstandings, as reported by several publications, revealing a lack of clear concepts in many cases. As an attempt to clarify or facilitate the comprehension of the most relevant terms in this field, the Spanish Society of Pediatric Intensive Care has prepared a Glossary of the most commonly used terms and expressions.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ética y reanimación cardiopulmonar pediátrica

Cardiopulmonary resuscitation (CPR) is a medical activity that involves major ethical issues. As in other areas of clinical ethics, CPR decisions must be based on the principles of autonomy, beneficence, nonmaleficence, and justice. The decision-making process is more difficult in emergency situations, and when the patient is a minor, the parents and the child's best interests must be taken into consideration. There are specific situations in which starting CPR is clearly indicated and others in which ceasing resuscitation maneuvers is justified. Do not attempt resuscitation orders must be respected by health staff. Other ethical issues involved in CPR include resuscitation of potential organ donors, learning CPR procedures, research in CPR, and the information given to the parents of children with cardiorespiratory arrest.