Resuscitation feedback and targeted education improves quality of pre-hospital resuscitation in Scotland

Compliance with CPR quality guidelines and survival after 30 days following out-of-hospital cardiac arrest. A retrospective study

BACKGROUND

Our study assessed the quality of cardiopulmonary resuscitation (CPR) given by emergency medical services in Southern Ostrobothnia Finland, as is advised in the international guidelines. The goal was to evaluate the current quality of CPR given to patients who suffered an out-of-hospital cardiac arrest and to examine possible measures for improving emergency medical services.

METHODS

A retrospective study was conducted on out-of-hospital cardiac arrest patients in Southern Ostrobothnia, Finland, during a three-year period. Confounding caused by each patient's individual medical history was addressed by calculating Charlson Comorbidity Index (CCI), a score describing individual's risk for death in 10 years. The Utstein analysis and the CPR metrics were acquired from the medical records hospital district in question and analysed in an orderly manner using SPSS. Descriptive statistics are presented as mean (SD) and median [IQR].

RESULTS

We found that of the 349 patients, 144 (41%) received ROSC, 96 (28%) survived to the hospital and 51 (15%) survived for at least 30 days. CPR metrics data were available for 181 patients. CCIs were 3.0 versus 5.0 (p = .157) for the ones who did and those who did not survive at least 30 days. Correspondingly, following metrics were as follows: Mean compression depth was 5.1 (1.3) versus 5.6 (0.8) cm (p = .088), median 28 [18;40] versus 40 [26;54]% of the compressions were in target depth (p = .015) and median compression rate was 113 [109;119] versus 112 [108;120] min-1 (p = .757). The median no-flow fraction was 5.1 [2.8;7.1] versus 3.7 [2.5;5.5] s (p = .073). Ventricular fibrillation (OR 8.74, 95% CI 2.89-26.43, p < .001), public location (OR 3.163, 95% CI 1.03-9.69, p = .044) and compression rate of 100-110/min (OR 7.923, 95% CI 2.11-29.82, p = .002) were related to survival.

CONCLUSION

Patients who suffered out-of-hospital cardiac arrest in Southern Ostrobothnia received CPR that met the international CPR quality target values. The proportion of unintentional pauses during CPR was low and the 30-day survival rate exceeded the international average.

Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis

BACKGROUND

Extensive research has been conducted into the effects of feedback interventions within many areas of healthcare, but prehospital emergency care has been relatively neglected. Exploratory work suggests that enhancing feedback and follow-up to emergency medical service (EMS) staff might provide staff with closure and improve clinical performance. Our aim was to summarise the literature on the types of feedback received by EMS professionals and its effects on the quality and safety of patient care, staff well-being and professional development.

METHODS

A systematic review and meta-analysis, including primary research studies of any method published in peer-reviewed journals. Studies were included if they contained information on systematic feedback to emergency ambulance staff regarding their performance. Databases searched from inception were MEDLINE, Embase, AMED, PsycINFO, HMIC, CINAHL and Web of Science, with searches last updated on 2 August 2022. Study quality was appraised using the Mixed Methods Appraisal Tool. Data analysis followed a convergent integrated design involving simultaneous narrative synthesis and random effects multilevel meta-analyses.

RESULTS

The search strategy yielded 3183 articles, with 48 studies meeting inclusion criteria after title/abstract screening and full-text review. Interventions were categorised as audit and feedback (n=31), peer-to-peer feedback (n=3), postevent debriefing (n=2), incident-prompted feedback (n=1), patient outcome feedback (n=1) or a combination thereof (n=4). Feedback was found to have a moderate positive effect on quality of care and professional development with a pooled effect of d=0.50 (95% CI 0.34, 0.67). Feedback to EMS professionals had large effects in improving documentation (d=0.73 (0.00, 1.45)) and protocol adherence (d=0.68 (0.12, 1.24)), as well as small effects in enhancing cardiac arrest performance (d=0.46 (0.06, 0.86)), clinical decision-making (d=0.47 (0.23, 0.72)), ambulance times (d=0.43 (0.12, 0.74)) and survival rates (d=0.22 (0.11, 0.33)). The between-study heterogeneity variance was estimated at σ2=0.32 (95% CI 0.22, 0.50), with an I2 value of 99% (95% CI 98%, 99%), indicating substantial statistical heterogeneity.

CONCLUSION

This review demonstrated that the evidence base currently does not support a clear single point estimate of the pooled effect of feedback to EMS staff as a single intervention type due to study heterogeneity. Further research is needed to provide guidance and frameworks supporting better design and evaluation of feedback interventions within EMS.

PROSPERO REGISTRATION NUMBER

CRD42020162600.

Feedback for Emergency Ambulance Staff: A National Review of Current Practice Informed by Realist Evaluation Methodology

Research suggests that feedback in Emergency Medical Services (EMS) positively affects quality of care and professional development. However, the mechanisms by which feedback achieves its effects still need to be better understood across healthcare settings. This study aimed to understand how United Kingdom (UK) ambulance services provide feedback for EMS professionals and develop a programme theory of how feedback works within EMS, using a mixed-methods, realist evaluation framework. A national cross-sectional survey was conducted to identify feedback initiatives in UK ambulance services, followed by four in-depth case studies involving qualitative interviews and documentary analysis. We used qualitative content analysis and descriptive statistics to analyse survey responses from 40 prehospital feedback initiatives, alongside retroductive analysis of 17 interviews and six documents from case study sites. Feedback initiatives mainly provided individual patient outcome feedback through "pull" initiatives triggered by staff requests. Challenges related to information governance were identified. Our programme theory of feedback to EMS professionals encompassed context (healthcare professional and organisational characteristics), mechanisms (feedback and implementation characteristics, psychological reasoning) and outcomes (implementation, staff and service outcomes). This study suggests that most UK ambulance services use a range of feedback initiatives and provides 24 empirically based testable hypotheses for future research.

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.

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.

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.

A Qualitative Study of Resident Experiences With Clinical Event Debriefing

OBJECTIVES

The facilitated discussion of events through clinical event debriefing (CED) can promote learning and wellbeing, but resident involvement is often limited. Although the graduate medical education field supports CED, interventions to promote resident involvement are limited by poor insight into how residents experience CED. The objective of this study was to characterize pediatric resident experiences with CED, with a specific focus on practice barriers and facilitators.

METHODS

We conducted this qualitative study between November and December 2020 at a large, free-standing children's hospital. We recruited pediatric residents from postgraduate years 1 to 4 to participate in virtual focus groups. Focus groups were digitally recorded, deidentified, and transcribed. Transcripts were entered into coding software for analysis. We analyzed the data using a modified grounded theory approach to identify major themes.

RESULTS

We conducted 4 mixed-level focus groups with 26 residents. Our analysis identified multiple barriers and facilitators of resident involvement in CED. Several barriers were logistical in nature, but the most salient barriers were derived from unique features of the resident role. For example, residents described the transience of their role as a barrier to both participating and engaging in CED. However, they described advancing professional experience and the desire for reflective learning as facilitators.

CONCLUSIONS

Residents in this study highlighted many factors affecting their participation and engagement in CED, including barriers related to the unique features of their role. On the basis of resident experiences, we propose several recommendations for CED practice that graduate medical education programs and hospitals should consider for supporting resident involvement in CED.

European Resuscitation Council Guidelines 2021: Systems saving lives

The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.

Effect of real-time and post-event feedback in out-of-hospital cardiac arrest attended by EMS - A systematic review and meta-analysis

Objectives

A systematic review to determine if cardiopulmonary resuscitation (CPR) guided by either real-time or post-event feedback could improve CPR quality or patient outcome compared to unguided CPR in out-of-hospital cardiac arrest (OHCA).

Methods

Four databases were searched; PubMed, Embase, CINAHL, and Cochrane Library in August 2020 for post 2010 literature on OHCA in adults. Critical outcomes were chest compression depth, rate and fraction. Important outcomes were any return of spontaneous circulation, survival to hospital and survival to discharge.

Results

A total of 9464 studies were identified with 61 eligibility for full text screening. A total of eight studies was included in the meta-analysis. Five studies investigated real-time feedback and three investigated post-event feedback. Meta-analysis revealed that real-time feedback statistically improves compression depth and rate while post-event feedback improved depth and fraction. Feedback did not statistically improve patient outcome but an improvement in absolute numbers revealed a clinical effect of feedback. Heterogenity varied from “might not be important” to “considerable”.

Conclusion

To significantly improve CPR quality real-time and post-event feedback should be combined. Neither real-time nor post event feedback could statistically be associated with patient outcome however, a clinical effect was detected. The conclusions reached were based on few studies of low to very low quality.

PROSPERO registration

CRD42019133881.

The effect of system performance improvement on patients with cardiac arrest: A systematic review

AIM

The aim of our review was to understand the effect of interventions to improve system-level performance on the clinical outcomes of patients with cardiac arrest.

METHODS

We searched PubMed, Ovid EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify randomised controlled trials and non-randomised studies published before July 21, 2020 reporting systems interventions to improve outcomes. Characteristics, study design, evaluation methods and outcomes of included studies were extracted. (PROSPERO registration CRD42020161882).

RESULTS

One cluster randomised trial and 26 non-randomised studies were included. There were 18 studies focusing on interventions for patients with out-of-hospital cardiac arrest and 9 studies for patients with in-hospital cardiac arrest. Interventions included implementation of a bundle of care strategy, evaluation of cardiopulmonary resuscitation (CPR) quality with feedback/debriefing, data surveillance, and CPR training programs. Although improved survival with favorable neurologic outcome at discharge after the implementation of specific interventions was found in 13 studies, improved survival to hospital discharge in 14 studies and improved survival to admission in 3 studies, there were still 7 studies showing no significant improvement of clinical outcomes after interventions.

CONCLUSION

Although only moderate to very low certainty of evidence exists to support the effect of system-level performance improvement on the clinical outcomes of patients, we recommend that organisations or communities evaluate their performance and target key areas with the goal to improve performance because of no known risks and the potential for a large beneficial effect.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Training of Basic Life Support Among Lay Undergraduates: Development and Implementation of an Evidence-Based Protocol

Background

Cardiopulmonary resuscitation (CPR) is an important method to improve the prognosis of patients with prehospital cardiac arrest (CA). Basic life support (BLS) is the first step in CPR and is usually performed by the first witness. However, the general population has poor BLS skills due to the lack of efficient and practical training strategy. Several training initiatives could be used to improve this situation, and the challenge is to find the most efficient one in detail according to the actual setting. Repeated and effective BLS training increase bystander’s confidence and willingness to perform BLS. Evidence-based instructional design is essential to improve the training of lay providers and ultimately improve resuscitation performance and patient outcomes.

Objective

1) To develop an evidence-based BLS training protocol for lay undergraduates; 2) to implement the protocol and 3) to evaluate the process of implementation.

Methods

Nine databases were searched to synthesize the best evidence. A protocol was formed by ranking evidence and considering university setting and students’ preferences. We implemented this training protocol and evaluated its effects.

Results

We achieved the three aims above. A total of 120 lay undergraduates received BLS training and retraining within 3 months. The students and teaching staff were satisfied with the training protocol and effect. The BLS training process was more clearly defined. The role of teaching assistants and the strategies to sustain training quality was proven to be crucial to the project’s success.

Conclusion

The development and implementation of an evidence-based protocol could elevate undergraduates’ BLS skill and confidence.

The use of body-worn cameras in pre-hospital resuscitation

Introduction:

Body-worn cameras (BWCs) are commonplace in many workplaces, but rare in the real-time audit of clinical performance in the pre-hospital setting. There are currently no data supporting the use of BWCs as an acceptable tool in clinical audit. Out-of-hospital cardiac arrest (OHCA) is a good candidate for audit – time critical, high stakes and not well observed. While the use of cameras to record such clinical data is demonstrably useful, it could be perceived by front line ambulance staff as intrusive and have a deleterious impact on clinical care. Investigating these potential barriers is important in ensuring that our effort to enhance the early phase of pre-hospital care through video audit does not have negative unintended consequences.

Methods:

Since 2012, the Resuscitation Research Group has used BWCs to provide a unique insight into how care is delivered by paramedics attending OHCAs. Paramedics attending arrests as part of the Resuscitation Rapid Response Unit (3RU) second-tier response wear a BWC, and collect real-time footage of these challenging, emotive clinical encounters. This footage has provided a unique medium for the audit of both individual technical task and team-oriented non-technical skills performance. We present the results of a survey in which paramedics share their views on the use of BWCs within their service.

Results:

A convenience sample of 83 questionnaires was collected. In relation to the primary outcome of the study, 81% (n = 53) of paramedics who responded to the statement, ‘the use of BWCs is a positive step for the service’, agreed or remained neutral, while only 19% (n = 12) disagreed.

Conclusion:

BWCs, and the supporting infrastructure and feedback processes, are an effective, acceptable and beneficial tool in the audit and analysis of team performance in pre-hospital resuscitation.

Self-Assessment Feedback Form Improves Quality of Out-of-Hospital CPR

Objective: Various continuous quality improvement (CQI) approaches have been used to improve quality of cardiopulmonary resuscitation (CPR) delivered at the scene of out-of-hospital cardiac arrest. We evaluated a post-event, self-assessment, CQI feedback form to determine its impact on delivery of CPR quality metrics. Methods: This before/after retrospective review evaluated data from a CQI program in a midsized urban emergency medical services (EMS) system using CPR quality metrics captured by Zoll Medical Inc. X-series defibrillator ECG files in adult patients (≥18 years old) with non-traumatic out-of-hospital cardiac arrest. Two 9-month periods, one before and one after implementation of the feedback form on December 31, 2013 were evaluated. Metrics included the mean and percentage of goal achievement for chest compression depth (goal: >5 centimeters [cm]; >90%/episode), rate (goal: 100-120 compressions/minute [min]), chest compression fraction (goal: ≥75%), and preshock pause (goal: <10 seconds [sec]). The feedback form was distributed to all EMS providers involved in the resuscitation within 72 hours for self-review. Results: A total of 439 encounters before and 621 encounters after were evaluated including basic life support (BLS) and advanced life support (ALS) providers. The Before Group consisted of 408 patients with an average age of 61 ± 17 years, 61.8% male. The After Group consisted of 556 patients with an average age of 61 ± 17 years, 58.3% male. Overall, combining BLS and ALS encounters, the mean CPR metric values before and after were: chest compression depth (5.0 cm vs. 5.5 cm; p < 0.001), rate (109.6/min vs 114.8/min; p < 0.001), fraction (79.2% vs. 86.4%; p < 0.001), and preshock pause (18.8 sec vs. 11.8 sec; p < 0.001), respectively. Overall, the percent goal achievement before and after were: chest compression depth (48.5% vs. 66.6%; p < 0.001), rate (71.8% vs. 71.7%, p = 0.78), fraction (68.1% vs. 91.0%; p < 0.001), and preshock pause (24.1% vs. 59.5%; p < 0.001), respectively. The BLS encounters and ALS encounters had similar statistically significant improvements seen in all metrics. Conclusion: This post-event, self-assessment CQI feedback form was associated with significant improvement in delivery of out-of-hospital CPR depth, fraction and preshock pause time.

Design and validation of a tool for the evaluation of the quality of Cardiopulmonary Resuscitation: SIEVCA-CPR 2.0®

INTRODUCTION

Currently, no system completely evaluates the quality of cardio pulmonary resusciation.

METHODS

A cross-sectional, prospective, longitudinal study using Delphi methodology was performed in three phases: preparatory, consultation and consensus. The validation was made by a prospective longitudinal study using the tool in the evaluation of 11 videos to determine the intra-class correlation coefficient (ICC) and the intra-subject (ICC-Initial), the latter repeated at four weeks (ICC-Final). We have determined intra-subject ICC: Initial-Final. This last result has been compared with a gold-standard value.

RESULTS

After the first phase, a 28-items list has been developed. In the second phase: ICC-Initial = 0.727 (p < .001), 95% CI (0.625, 0.801), ICC-Final = 0.860 (p < .001), 95% CI (0.807; 0.898) and ICC Initial-Final = 0.880 (p < .001), 95% CI (0.835; 0.913). Finally, an online tool has been developed (SIEVCA 2.0).

CONCLUSION

The designed tool presents good reliability in the assessment of cardio pulmonary resuscitation and it is useful in different fields and scenarios.

Improvements in the quality of advanced life support and patient outcome after implementation of a standardized real-life post-resuscitation feedback system

BACKGROUND

Educational aspects in the training of advanced life support (ALS) represent a key role in critical care management of patients with out-of-hospital cardiac arrest (OHCA) and received special attention in guidelines of various international societies. While a positive association of feedback on ALS performance in training conditions is well established, data on the impact of a real-life post-resuscitation feedback on both ALS quality and outcome remain scarce and inconclusive. We aimed to elucidate the impact of a standardized post-resuscitation feedback on quality of ALS and improvements in patient outcome, in a real-life out-of-hospital setting.

METHODS

We prospectively enrolled and analyzed 2209 patients presenting with OHCA receiving resuscitation attempts by the municipal emergency medical service (EMS) of Vienna over a two-year period. A standardized post-resuscitation feedback protocol was delivered to the respective EMS-team to elucidate its impact on the quality of ALS.

RESULTS

We observed that both chest compression rates and ratios were in accordance to recommendations of recent guidelines. While interruptions of chest compressions longer than 30s declined during the observation period (-6.5%) rates of the recommended chest compressions during defibrillator-charging periods increased (+8.9%). Since the percentage of ROSC and 30-day survival remained balanced, the frequencies of both survival until hospital discharge (+6.3%) and favorable neurological outcome (+16%) in survivors significantly increased during the observation period.

CONCLUSION

Improvements in the quality of advanced life support as well the patient outcome were observed after the implementation of a standardized post-resuscitation feedback protocol.

Clinical Performance Feedback to Paramedics: What They Receive and What They Need

OBJECTIVES

Performance feedback is not always well utilized in healthcare. To more effectively incorporate it, we used a discussion of current feedback systems to explore paramedics' perceived needs regarding feedback and to understand what feedback would improve their performance as healthcare providers.

METHODS

We used a qualitative methodology with semistructured interviews of paramedics to explore perceptions and desires for feedback. Interpretive descriptive analysis was performed with continuous recruitment until thematic saturation was achieved. Themes were identified and a coding system was developed by two investigators separately and merged by consensus. The analysis was audited by a third investigator, and a member check was performed.

RESULTS

Many different ideas were discussed that were analyzed to develop several major recurrent themes. One such theme was positive perception of feedback by paramedics. Despite the positive perceptions discussed, the shortcomings of current systems were also frequently discussed as were perceived barriers to receiving meaningful feedback. The idea of following up on patients' courses/outcomes also arose frequently during the interviews. In addition, feedback and its interaction with mental health emerged as a theme in terms of its potential for both positive and negative impact. Finally, suggestions about the future were also common with paramedics providing thoughts regarding what future systems could be developed or what changes could be made to provide them with meaningful feedback.

CONCLUSIONS

Our findings show how paramedics perceive feedback, but still note how barriers may impair its uptake and how it may affect their mental health. Our participants also made recommendations about what they would want to see in future feedback systems. This information can provide the foundation to improve current feedback systems or structure new ones to allow paramedics to continue to develop themselves as healthcare professionals.

Does an individualized feedback mechanism improve quality of out-of-hospital CPR?

BACKGROUND

Despite its prevalence, survival from out-of-hospital cardiac arrest remains low. High quality CPR has been associated with improved survival in cardiac arrest patients. In early 2014, a program was initiated to provide feedback on CPR quality to prehospital providers after every treated cardiac arrest.

OBJECTIVE

To assess whether individualized CPR feedback was associated with improved CPR quality measures in the prehospital setting.

METHODS

This before and after retrospective review included all treated adult out-of-hospital cardiac arrest in patients in an urban community. Data was compared prior to and after the initiation of the CPR feedback program. We compared the percent of encounters reaching the system defined benchmarks as well as the average values for compression fraction, compression rate, compression depth, and pre-shock pause in the before period compared to the after period.

RESULTS

There were 159 encounters in the before period and 117 in the after. Compared to the before group, the after group had higher average compression rates (111.2/min vs 113.8/min; p=0.042), increased compression depths (4.9cm vs 5.6cm; p<0.001), and increased rates of benchmark achievement for compression depth greater than 5cm (48.1% vs 72.6%; p<0.001). No significant difference was noted in pre-shock pause (21.4s vs 14.7s; p=0.068). Additionally, no difference was noted between groups for compression fraction, though goal achievement was high in both groups.

CONCLUSION

We found that individual CPR feedback is associated with marginally improved quality of CPR in the prehospital setting. Further investigation with larger samples is warranted to better quantify this effect.

The impact of post-resuscitation feedback for paramedics on the quality of cardiopulmonary resuscitation

PURPOSE

The Guidelines place emphasis on high-quality cardiopulmonary resuscitation (CPR). This study aims to measure the impact of post-resuscitation feedback on the quality of CPR as performed by ambulance personnel.

MATERIALS AND METHODS

Two ambulances are dispatched for suspected cardiac arrest. The crew (driver and paramedic) of the first arriving ambulance is responsible for the quality of CPR. The crew of the second ambulance establishes an intravenous access and supports the first crew. All resuscitation attempts led by the ambulance crew of the study region were reviewed by two research paramedics and structured feedback was given based on defibrillator recording with impedance signal. A 12-months period before introduction of post-resuscitation feedback was compared with a 19-months period after introduction of feedback, excluding a six months run-in interval. Quality parameters were chest compression fraction (CCF), chest compression rate, longest peri-shock pause and longest non-shock pause.

RESULTS

In the pre-feedback period 55 cases were analyzed and 69 cases in the feedback period. Median CCF improved significantly in the feedback period (79% vs 86%, p<0.001). The mean chest compression rate was within the recommended range of 100-120/min in 87% of the cases in the pre-feedback period and in 90% of the cases in the feedback period (p=0.65). The duration of longest non-shock pause decreased significantly (40s vs 19s, p<0.001), the duration of the longest peri-shock pause did not change significantly (16s vs 13s, p=0.27).

CONCLUSION

Post-resuscitation feedback improves the quality of resuscitation, significantly increasing CCF and decreasing the duration of longest non-shock pauses.

An evaluation of three methods of in-hospital cardiac arrest educational debriefing: The cardiopulmonary resuscitation debriefing study

BACKGROUND

The use of cardiac arrest educational debriefing has been associated with improvements in cardiopulmonary resuscitation (CPR) quality and patient outcome. The practical challenges associated with delivering some debriefing approaches may not be generalisable to the UK health setting. The aim of this study was to evaluate the deliverability and effectiveness of three cardiac arrest debriefing approaches that were tailored to UK working practice.

METHODS

We undertook a before/after study at three hospital sites. During the post-intervention period of the study, three cardiac arrest educational debriefing models were implemented at study hospitals (one model per hospital). To evaluate the effectiveness of the interventions, CPR quality and patient outcome data were collected from consecutive adult cardiac arrest events attended by the hospital cardiac arrest team. The primary outcome was chest compression depth.

RESULTS

Between November 2011 and July 2014, 1198 cardiac arrest events were eligible for study inclusion (782 pre-intervention; 416 post-intervention). The quality of CPR was high at baseline. During the post-intervention period, cardiac arrest debriefing interventions were delivered to 191 clinicians on 344 occasions. Debriefing interventions were deliverable in practice, but were not associated with a clinically important improvement in CPR quality. The interventions had no effect on patient outcome.

CONCLUSION

The delivery of these cardiac arrest educational debriefing strategies was feasible, but did not have a large effect on CPR quality. This may be attributable to the high-quality of CPR being delivered in study hospitals at baseline.

TRIAL REGISTRATION

ISRCTN39758339.

Mechanical chest compression does not seem to improve outcome after out-of hospital cardiac arrest. A single center observational trial

AIM

Recently three large post product placement studies, comparing mechanical chest compression (cc) devices to those who received manual cc, found equivalent outcome results for both groups. Thus the question arises whether those results could be replicated using the devices on a daily routine.

METHODS

We prospectively enrolled 948 patients over a 12 months period. Chi-Square test and Mann-Whitney-U test were used to assess differences between "manual" and "mechanical" cc subgroups. Uni- and multivariate Cox regression hazard analysis were used to assess the influence of cc type on survival.

RESULTS

A mechanical cc device was used in 30.1% (n=283) cases. Patients who received mechanical cc had a significantly worse neurological outcome - measured in cerebral performance category (CPC) - than the manual cc group (56.8% vs. 78.6%, p=0.009). Patients receiving mechanical cc were significantly younger, more were male and were more likely to have bystander CPR and an initially shock-able ECG rhythm. There was no difference in the quality of CPR that might explain the worse outcome in mechanical cc patients.

CONCLUSION

Even with high quality CPR in both, manual and mechanical cc groups, outcome in patients who received mechanical cc was significantly worse. The anticipated benefits of a higher compression ratio and a steadier compression depth of a mechanical cc device remain uncertain. In this study selection for mechanical cc was not standardized, and was non-random. This merits further investigation. Further research on how mechanical cc is chosen and used should be considered.

CLINICAL TRIAL REGISTRATION

https://ekmeduniwien.at/core/catalog/2013/ (EK-Nr:1221/2013).

The impact of prehospital resuscitation research on in-hospital care

Since their introduction over 40 years ago, paramedics have been trained to deliver select advanced life support interventions in the community with the goal of reducing morbidity and mortality from cardiovascular disease and trauma. The ensuing decades witnessed a great deal of interest in paramedic care, with an exponential growth in prehospital resuscitation research. As part of the CJEM series on emergency medical services (EMS), we review recent prehospital research in out-of-hospital cardiac arrest and discuss how, in a novel departure from the origins of EMS, prehospital research is beginning to influence in-hospital care. We discuss emerging areas of study related to cardiopulmonary resuscitation (CPR) quality, therapeutic hypothermia, termination of resuscitation, and the use of end-tidal carbon dioxide measurement, as well as the subtle ripple effects that prehospital research is having on the broader understanding of the management of these critically ill patients.

Tanshinone IIA Downregulates HMGB1 and TLR4 Expression in a Spinal Nerve Ligation Model of Neuropathic Pain

Fifty-four Sprague-Dawley rats weighing 200~240 g were randomly divided into sham-operated group (sham group), vehicle-treated SNL group (model group), and Tan IIA-treated SNL group (Tan IIA group). Tan IIA was administered intraperitoneally to rats in the Tan IIA-treated group at a dose of 30 mg/kg daily for 14 days after SNL surgery. Paw withdrawal mechanical thresholds (PWTs) and paw withdrawal thermal latencies (PWLs) were measured. High-mobility group box 1 (HMGB1) and Toll-like Receptor 4 (TLR4) mRNA and protein expression in the spinal cord were measured. Tumour necrosis factor alpha (TNF-α), interleukin-1 beta (IL-1β), and interleukin-10 (IL-10) in the spinal cord were measured, too. Both the mechanical and heat pain thresholds were significantly decreased. After Tan IIA treatment, HMGB1, and TLR4 mRNA and protein levels, the expression of TNF-α and IF-1β was reduced significantly. In conclusion, Tanshinone IIA reversed SNL-induced thermal hyperalgesia and mechanical allodynia and downregulated HMGB1 and TLR4 levels and inhibited the HMGB1-TLR4 pathway. Tanshinone IIA inhibited TNF-α and IL-1β expression but not IF-10 expression in the spinal cords of SNL rats. These results indicate that Tanshinone IIA inhibited SNL-induced neuropathic pain via multiple effects, and targeting the HMGB1-TLR4 pathway could serve as the basis of new antinociceptive agents.

Debriefing after resuscitation

PURPOSE OF REVIEW

Evidence of suboptimal cardiopulmonary resuscitation (CPR) delivery in practice has driven interest in strategies to improve CPR quality. Early data suggest that debriefing may be an effective strategy. In this review, we analyse types of debriefing and the evidence to support their usage.

RECENT FINDINGS

There is a general lack of standardization in terminology and methods used for debriefing that limits evaluation. Debriefing interventions generally take two different formats. Hot debriefing is one where individuals or teams are provided with debriefing immediately after the event. Although perhaps the most widely used and easiest to implement, research evidence for its effectiveness is scant. Cold debriefing, where individuals or teams are provided with feedback sometime after the event, is associated with improvements in process and patient outcomes. Such feedback usually involves the use of objective performance data, such as defibrillator downloads or videotape records. Before and after cohort studies have found that both verbal debriefing in groups and individual written feedback seem to be associated with an improvement in performance.

SUMMARY

Debriefing is a useful strategy to improve resuscitation performance, but the optimal delivery method remains unclear. Future high-quality research is required to identify the most effective form of debriefing.

Real-time audiovisual feedback system in a physician-staffed helicopter emergency medical service in Finland: the quality results and barriers to implementation

OBJECTIVES

To evaluate the quality of cardiopulmonary resuscitation (CPR) in a physician staffed helicopter emergency medical service (HEMS) using a monitor-defibrillator with a quality analysis feature. As a post hoc analysis, the potential barriers to implementation were surveyed.

METHODS

The quality of CPR performed by the HEMS from November 2008 to April 2010 was analysed. To evaluate the implementation rate of quality analysis, the HEMS database was screened for all cardiac arrest missions during the study period. As a consequence of the observed low implementation rate, a survey was sent to physicians working in the HEMS to evaluate the possible reasons for not utilizing the automated quality analysis feature.

RESULTS

During the study period, the quality analysis was used for 52 out of 187 patients (28%). In these cases the mean compression depth was < 40 mm in 46% and < 50 mm in 96% of the 1-min analysis intervals, but otherwise CPR quality corresponded with the 2005 resuscitation guidelines. In particular, the no-flow fraction was remarkably low 0.10 (0.07, 0.16). The most common reasons for not using quality-controlled CPR were that the device itself was not taken to the scene, or not applied to the patient, because another EMS unit was already treating the patient with another defibrillator.

CONCLUSIONS

When quality-controlled CPR technology was used, the indicators of good quality CPR as described in the 2005 resuscitation guidelines were mostly achieved albeit with sufficient compression depth. The use of the well-described technology in improving patient care was low. Wider implementation of the automated quality control and feedback feature in defibrillators could further improve the quality of CPR on the field.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT00951704).