In-hospital resuscitation: association between ACLS training and survival to discharge

Are Italian Newly Licensed Nurses Ready? A Study on Self-Perceived Clinical Autonomy in Critical Care Scenarios

The experience and self-confidence of healthcare professionals play critical roles in reducing anxiety levels during emergencies. It is important to recognize the potential impact of anxiety on performance. To enhance preparedness and confidence in managing emergencies, healthcare professionals benefit from regular training and simulations. Additionally, repeated exposure to emergency scenarios can help modulate physiological responses. Managing anxiety effectively is key, as heightened sympathetic stimulation associated with anxiety can adversely affect performance. This study aimed to investigate nurses' self-assessed ability to manage emergency guidelines and their self-confidence in performing tasks in critical care settings. A questionnaire was provided to 1097 nurses. We compared the self-confidence of experienced nurses (ENs) and newly licensed nurses (NLNs) in managing emergency department shifts or critical patients, and found that ENs are more confident in these scenarios. This phenomenon was also observed in subjects who had taken simulation courses, although they were still a low percentage. Most NLNs feel sufficiently ready to work in medium-intensity wards. Attending advanced training courses enhances nurses' self-confidence and may improve patient safety management., improving patient recovery, and minimizing errors. Attending courses improves the perception of autonomy of nurses in different scenarios.

Impact of accredited advanced life support course participation on in-hospital cardiac arrest patient outcomes: A systematic review

Aim

Advanced life support courses have a clear educational impact; however, it is important to determine whether participation of one or more members of the resuscitation team in an accredited advanced life support course improves in-hospital cardiac arrest patient survival outcomes.

Methods

We searched EMBASE.com, Medline, Cochrane and CINAHL from inception to 1 November 2022. Included studies were randomised or non-randomised interventional studies assessing the impact of attendance at accredited life support courses on patient outcomes. Accredited life support courses were classified into 3 contexts: Advanced Life Support (ALS), Neonatal Resuscitation Training (NRT), and Helping Babies Breathe (HBB). Existing systematic reviews were identified for each of the contexts and an adolopment process was pursued. Appropriate risk of bias assessment tools were used across all outcomes. When meta-analysis was appropriate a random-effects model was used to produce a summary of effect sizes for each outcome.

Results

Of 2714 citations screened, 19 studies (1 ALS; 7 NRT; 11 HBB) were eligible for inclusion. Three systematic reviews which satisfied AMSTAR-2 criteria for methodological quality, included 16 of the studies we identified in our search. Among adult patients all outcomes including return of spontaneous circulation, survival to discharge and survival to 30 days were consistently better with accredited ALS training. Among neonatal patients there were reductions in stillbirths and early neonatal mortality.

Conclusion

These results support the recommendation that accredited advanced life support courses, specifically Advanced Life Support, Neonatal Resuscitation Training, and Helping Babies Breathe improve patient outcomes.

Training, knowledge, experience and perceptions regarding cardiopulmonary resuscitation of doctors at an academic hospital in central South Africa

Background

Cardiopulmonary resuscitation (CPR) improves immediate survival and survival to discharge in patients with cardiac arrest in hospital. Without frequent retraining in CPR, healthcare providers may lose their skills and knowledge earlier than the recommendation of CPR retraining every two years.

Objectives

To determine the competencies of doctors at an academic hospital regarding CPR training, knowledge, experience and perceptions.

Methods

A custom-designed questionnaire reviewed by CPR providers was distributed to doctors to obtain information on CPR training, exposure to and perceptions of CPR retraining, and CPR knowledge. The knowledge component of the questionnaire comprised questions on basic, advanced cardiac, paediatric, neonatal and obstetric life support.

Results

Of the 245 participants, 22.5% achieved competency (a mark of ≥ 80%) for the knowledge component of the questionnaire. The majority of participants had not undertaken retraining after two years, although 96.7% of participants felt that keeping up-to-date with CPR guidelines would improve patient outcomes. The most common reasons provided for not feeling confident in performing CPR were related to training.

Conclusion

Doctors at the academic hospital in this study are currently not adequately trained in CPR, which is reflected by their lack of CPR knowledge. Lack of training seems to be the most common reason for not feeling confident, and being too busy to attend these retraining courses was reported as the most common reason. It further seems that very few of the departments have CPR training for their doctors. A regular in-hospital CPR training program may improve doctor's CPR knowledge.

Neurological outcomes after traumatic cardiopulmonary arrest: a systematic review

Background

Despite appropriate care, most patients do not survive traumatic cardiac arrest, and many survivors suffer from permanent neurological disability. The prevalence of non-dismal neurological outcomes remains unclear.

Objectives

The aim of the current review is to summarize and assess the quality of reporting of the neurological outcomes in traumatic cardiac arrest survivors.

Data sources

A systematic review of Embase, Medline, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ProQuest databases was performed from inception of the database to July 2020.

Study eligibility criteria

Observational cohort studies that reported neurological outcomes of patients surviving traumatic cardiac arrest were included.

Participants and interventions

Patients who were resuscitated following traumatic cardiac arrest.

Study appraisal and synthesis methods

The quality of the included studies was assessed using ROBINS-I (Risk of Bias in Non-Randomized Studies - of Interventions) for observational studies.

Results

From 4295 retrieved studies, 40 were included (n=23 644 patients). The survival rate was 9.2% (n=2168 patients). Neurological status was primarily assessed at discharge. Overall, 45.8% of the survivors had good or moderate neurological recovery, 29.0% had severe neurological disability or suffered a vegetative state, and 25.2% had missing neurological outcomes. Seventeen studies qualitatively described neurological outcomes based on patient disposition and 23 studies used standardized outcome scales. 28 studies had a serious risk of bias and 12 had moderate risk of bias.

Limitations

The existing literature is characterized by inadequate outcome reporting and a high risk of bias, which limit our ability to prognosticate in this patient population.

Conclusions or implications of key findings

Good and moderate neurological recoveries are frequently reported in patients who survive traumatic cardiac arrest. Prospective studies focused on quality of survivorship in traumatic arrest are urgently needed.

Level of evidence

Systematic review, level IV.

PROSPERO registration number

CRD42020198482.

A simulation-based pilot study of crisis checklists in the emergency department

Checklists can improve adherence to standardized procedures and minimize human error. We aimed to test if implementation of a checklist was feasible and effective in enhancing patient care in an emergency department handling internal medicine cases. We developed four critical event checklists and confronted volunteer teams with a series of four simulated emergency scenarios. In two scenarios, the teams were provided access to the crisis checklists in a randomized cross-over design. Simulated patient outcome plus statement of the underlying diagnosis defined the primary endpoint and adherence to key processes such as time to commence CPR represented the secondary endpoints. A questionnaire was used to capture participants' perception of clinical relevance and manageability of the checklists. Six teams of four volunteers completed a total of 24 crisis sequences. The primary endpoint was reached in 8 out of 12 sequences with and in 2 out of 12 sequences without a checklist (Odds ratio, 10; CI 1.11, 123.43; p = 0.03607, Fisher's exact test). Adherence to critical steps was significantly higher in all scenarios for which a checklist was available (performance score of 56.3% without checklist, 81.9% with checklist, p = 0.00284, linear regression model). All participants rated the checklist as useful and 22 of 24 participants would use the checklist in real life. Checklist use had no influence on CPR quality. The use of context-specific checklists showed a statistically significant influence on team performance and simulated patient outcome and contributed to adherence to standard clinical practices in emergency situations.

[Education for resuscitation]

Diese Leitlinien des European Resuscitation Council basieren auf dem internationalen wissenschaftlichen Konsens 2020 zur kardiopulmonalen Reanimation mit Behandlungsempfehlungen (International Liaison Committee on Resuscitation 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations [ILCOR] 2020 CoSTR). Dieser Abschnitt bietet Bürgern und Angehörigen der Gesundheitsberufe Anleitungen zum Lehren und Lernen der Kenntnisse, der Fertigkeiten und der Einstellungen zur Reanimation mit dem Ziel, das Überleben von Patienten nach Kreislaufstillstand zu verbessern.

Optimizing the management of inpatient cardiac arrest

ABSTRACT

Cardiac arrest is a common event in the inpatient setting, and although attempts have been made to simplify the approach to its management via systemwide training in CPR and Advanced Cardiac Life Support, significant challenges remain in implementing these guidelines in the management of cardiac arrest.

ACLS interventional skills: Are we as good as we should be?

OBJECTIVE

This study evaluated the competence of Advanced Cardiac Life Support certified personnel at hands-on ACLS skills.

METHODS

The observational, cross-sectional study assessed participants' subjective confidence and objective skills using the ACLS mega code examination. Testing was performed with a Laerdal manikin and standardized code carts.

RESULTS

Participants had a 12% (6% to 22%, 95% CI) pass rate for the stable tachyarrhythmia scenario and a 57% (44% to 69%, 95% CI) pass rate for the unstable tachyarrhythmia scenario. The most significant skills missed were appropriate medications and postconversion maintenance in the stable scenario and appropriate energy selection and successful shock delivery for the unstable scenario.

CONCLUSIONS

ACLS providers feel confident in their ACLS skills; however, actual performance demonstrated poor performance in the management of patients with stable and unstable tachyarrhythmias. The recommendation is to observe initial and recertification ACLS classes to investigate the standard to which these core skills are being taught and evaluated.

European Resuscitation Council Guidelines 2021: Education for resuscitation

These European Resuscitation Council education guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidance to citizens and healthcare professionals with regard to teaching and learning the knowledge, skills and attitudes of resuscitation with the ultimate aim of improving patient survival after cardiac arrest.

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.

[Internal hospital emergency management : Concepts for optimization of patient safety in hospitals]

Critical incidents in hospitals can often be predicted hours before the event and can mostly be detected earlier and presumably avoided. Quality management programs from US hospitals to reduce deaths following a severe postoperative complication (failure to rescue, FTR), have in this form not yet become established in Germany. A sensitive score-based early warning system for looming complications is decisive for successful in-hospital emergency management. In addition to measurement rounds where the frequency is adapted to the severity, this includes effective communication of the results to the ward physician, who in the best case scenario solves the problem alone. If the deployment of a medical rapid response emergency team (MET) is necessary, there must be clear chain of alarm pathways and the personnel on the ward must be able to take initial bridging action until the MET arrives. The MET provides 24/7 emergency and intensive medical expertise for peripheral wards and must be familiar with the location, well-equipped and trained. Communication skills are particularly required not only to be able to handle the immediate emergency situation but also to organize the downstream diagnostics and escalation of treatment; however, the MET is only one of the links in the in-hospital rescue chain, which can only improve the patient outcome when alerted in a timely manner. Feedback systems, such as participation in the German Resuscitation Registry, allow reflection of one's own performance in a national comparison. The chances offered by a MET will only be fully realized when it is integrated into an in-hospital emergency concept and this determines the added value for patient safety.

Simulation in Neurocritical Care: Past, Present, and Future

Simulation-based medical education is a technique that leverages adult learning theory to train healthcare professionals by recreating real-world scenarios in an interactive way. It allows learners to emotionally engage in the assessment and management of critically ill patients without putting patients at risk. Learners are encouraged to work at the edge of their expertise to promote growth and are provided with feedback to nurture development. Thus, the training is targeted to the learner, not the patient. Despite its origins as a teaching tool for neurological diseases, simulation-based medical education has been historically abandoned by neurocritical care educators. In contrast, other critical care educators have embraced the technique and built an impressive foundation of literature supporting its use. Slowly, neurocritical care educators have started experimenting with simulation-based medical education and sharing their results. In this review, we will investigate the historical origins of simulation in the neurosciences, the conceptual framework supporting the technique, current applications, and future directions.

The timing of testing influences skill retention after basic life support training: a prospective quasi-experimental study

BACKGROUND

Proper basic life support (BLS) is key in improving the survival of out-of-hospital cardiac arrest. BLS skills deteriorate in three to 6 months after training. One method to improve skill retention may be using the "testing effect" to test skills at the end of a BLS course. The aim of our study was to investigate whether either testing or the timing of such testing after BLS training have any influence on skill retention.

METHODS

This was a post-test only, partial coverage, prospective quasi-experimental study designed to evaluate a BLS training course among 464 fifth year medical students at Semmelweis University in the first semester of 2013/2014. Groups were systematically but non-randomly assigned to either a control group that took no exam or one of two experimental groups that took an exam (N = 179, NoExam group; N = 165, EndExam group - exam at the end of the BLS training; N = 120, 3mExam group - exam 3 months after the BLS training). The ability to perform ten prescribed essential BLS steps was evaluated during a skill retention assessment 2 months after the course in the NoExam, 2 months after the course (and the exam) in the EndExam and 5 months after the course (2 months after the exam) in the 3mExam group to measure skill retention and the effect of our intervention. Scores were calculated for each BLS step, and also summed up as a total score. We used Kruskal-Wallis test to assess differences in skill retention.

RESULTS

Overall, NoExam and EndExam groups showed similar skill retention. The mean total score (and many of the sub-scores) of students was significantly higher in the 3mExam group compared to both the NoExam and the EndExam groups, and there was no difference in the total score (and many of the sub-scores) of the latter two groups. The 3mExam group had less variability in total scores (and many of the sub-scores) than the other two groups.

CONCLUSION

Our study provides evidence that testing these skills 3 months after BLS training may be more effective than either testing immediately at the end of the course or no testing at all.

Code blue pit crew model: A novel approach to in-hospital cardiac arrest resuscitation

BACKGROUND

Mortality from in-hospital cardiac arrests remains a large problem world-wide. In an effort to improve in-hospital cardiac arrest mortality, there is a renewed focus on team training and operations. Here, we describe the implementation of a "pit crew" model to provide in-hospital resuscitation care.

METHODS

In order to improve our institution's code team organization, we implemented a pit crew resuscitation model. The model was introduced through computer-based modules and lectures and was reemphasized at our institution-based ACLS training and mock code events. To assess the effect of our model, we reviewed pre- and post-pit crew implementation data from five sources: defibrillator downloads, a centralized hospital database, mock codes, expert-led debriefings, and confidential surveys. Data with continuous variables and normal distribution were analyzed using a standard two-sample t-test. For yes/no categorical data either a Z-test for difference between proportions or Chi-square test was used.

RESULTS

There were statistically significant improvements in compression rates post-intervention (mean rate 133.5 pre vs. 127.9 post, two-tailed, p = 0.02) and in adequate team communication (33% pre vs. 100% post; p = 0.05). There were also trends toward a reduction in the number of shockable rhythms that were not defibrillated (32.7% pre vs. 18.4% post), average time to shock (mean 1.96 min pre vs. 1.69 min post), and overall survival to discharge (31% pre vs. 37% post), though these did not reach statistical significance.

CONCLUSION

Implementation of an in-hospital, pit crew resuscitation model is feasible and can improve both code team communication as well as key ACLS metrics.

Cardiopulmonary resuscitation practices in the Netherlands: results from a nationwide survey

Background

Survival rates after in-hospital cardiac arrest are low and vary across hospitals. The ERC guidelines state that more research is needed to explore factors that could influence survival. Research into the role of cardiopulmonary resuscitation (CPR) practices is scarce. The goal of this survey is to gain information about CPR practices among hospitals in the Netherlands.

Methods

A survey was distributed to all Dutch hospital organizations (n = 77). Items investigated were general hospital characteristics, pre-, peri- and post-resuscitation care. Characteristics were stratified by hospital teaching status.

Results

Out of 77 hospital organizations, 71 (92%) responded to the survey, representing 99 locations. Hospitals were divided into three categories: university hospitals (8%), teaching hospitals (64%) and non-teaching hospitals (28%). Of all locations, 96% used the most recent guidelines for Advanced Life Support and 91% reported the availability of a Rapid Response System. Training frequencies varied from twice a year in 41% and once a year in 53% of hospital locations. The role of CPR team leader and airway manager is most often fulfilled by (resident) anaesthetists in university hospitals (63%), by emergency department professionals in teaching hospitals (43%) and by intensive care professionals in non-teaching hospitals (72%). The role of airway manager is most often attributed to (resident) anaesthetists in university hospitals (100%), and to intensive care professionals in teaching (82%) and non-teaching hospitals (79%).

Conclusion

The majority of Dutch hospitals follow the ERC guidelines but there are differences in the presence of an ALS certified physician, intensity of training and participation of medical specialties in the fulfilment of roles within the CPR-team.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4166-2) contains supplementary material, which is available to authorized users.

Factors associated with outcomes in traumatic cardiac arrest patients without prehospital return of spontaneous circulation

BACKGROUND

Prognostic factors for the outcomes in traumatic cardiac arrest (TCA) patients transported to hospitals without prehospital return of spontaneous circulation (ROSC) remain uncertain. The aim of this study is to investigate factors associated with outcomes in TCA patients without prehospital ROSC.

METHODS

We conducted a retrospective cohort study using a multi-institutional, 5-year database. Only TCA patients without prehospital ROSC were included. The primary outcome was ROSC in the emergency department (ED), and the secondary outcome was 30-day survival. Logistic regression analysis was performed to determine the factors associated with primary and secondary outcomes.

RESULTS

Among 463 TCA patients, 73 (16%) had ROSC during ED resuscitation, and among those with sustained ROSC, 10 (14%) survived for at least 30 days. Injury severity score ≧ 16 (OR, 0.06; 95% CI: 0.02-0.20), trauma center admission (OR, 2.69; 95% CI: 1.03-7.03), length of ED resuscitation (OR, 0.98; 95% CI: 0.96-0.99), and total resuscitation length > 20 min (OR, 0.21; 95% CI: 0.08-0.54) were associated with ROSC.

CONCLUSIONS

In TCA patients transported to hospitals without prehospital ROSC, resuscitation attempts could be beneficial. We should aim to resuscitate patients as soon as possible with appropriate treatments for trauma patients, early activation of trauma team, and then, as a result, shorter resuscitation time will be achieved.

Impact of adult advanced cardiac life support course participation on patient outcomes-A systematic review and meta-analysis

OBJECTIVES

The objective of this study was to evaluate the impact of the prior participation of one or more members of the adult resuscitation team in an accredited advanced life support course on patient outcomes (return of spontaneous circulation, survival to discharge, survival to 30 days, and survival to 1 year).

METHODS

A systematic search of Medline, CINAHL, Embase, ERIC, and Cochrane databases was conducted through 6 March 2018. We included randomised and observational studies in any language. Reviewers independently extracted data on study design and outcomes. The GRADE approach was used to evaluate the overall quality of evidence for each outcome.

RESULTS

Nine hundred and ninety-two articles were identified of which eight observational studies were included. No randomised controlled trials were identified. Meta-analysis showed an association between participation of healthcare personnel in an advanced life support course and return of spontaneous circulation [odds ratio (OR) 1.64; 95% CI 1.12-2.41, risk difference (RD) 0.10 (95% CI 0.03-0.17)]. Life support training showed a significant absolute effect on patient survival to discharge [RD 0.10, 95% CI 0.01-0.18], but non-significant relative effect [OR 2.12; 95% CI 0.98-4.57]. Data from one study showed an association with survival to 30 days [OR 7.15; 95% CI 1.61-31.69, RD 0.18 (95% CI 0.08-0.27)].

CONCLUSION

The inference of this review is that the advanced life support courses have a positive impact upon return of spontaneous circulation and survival to hospital discharge. The data also implies a positive impact upon survival to 30 days of adult cardiac arrest patients.

Ethical Issues in Registry Research: In-Hospital Resuscitation as a Case Study

Research based on registry studies involves significant ethical issues. Using detailed information about one registry concerning in-hospital resuscitation, we present issues concerning informed consent, access to identifiable medical information, and benefit for participants. In addition, multiple methodological difficulties have indirect implications for the ethical conduct of registry research, including consensus about variable definitions, validity and reliability for clinical decisions, sample sizes, and sources of data. Both direct and indirect ethical issues are examined from the viewpoint of accepted regulations and codes regarding ethical conduct of research; specific examples of more or less ethical solutions to the problems are presented from published research.

Seeking an Explanation for the Poor Uptake of In-Hospital AED Programs

The automated external defibrillator (AED) has been adopted by emergency service personnel as a first-line intervention in the management of out-of-hospital cardiac arrest (OHCA). AED leads to more successful Advanced Cardiac Life Support; consequently, national resuscitation organisations worldwide have recommended that nurses and doctors also integrate AEDs as a component of their basic life-support response to cardiac arrest. Despite these recommendations, the implementation of AED programs within hospitals has been generally sporadic and isolated. A continuation of this situation will most likely disturb and perplex nurses and patients, as they are key stakeholders with respect to upholding recommended BLS practices. In the absence of any explanation from change agents within hospitals, this paper seeks, by way of a pilot study and a review of the literature, to identify the extent of the problem and identify factors contributing to the relatively slow uptake of this device. We argue that nurses and other first responders to in-hospital cardiac arrest (CA) have much to gain, in the context of Occupational Health Safety and Welfare (OHS and W), from ready access to AEDs. Cost factors are also considered, with initial cost of AED purchase likely to be a major concern for managers of hospital budgets. The issues we discuss in this paper clearly support the need for further research to (a) explain the nature of public hospital resistance to AEDs and (b) to consider whether AEDs will provide practical advantages to public hospitals from an occupational, social and economic perspective.

Attitudes of Doctors Working in Abant Izzet Baysal University Health Research and Application Center on Cardiopulmonary Resuscitation

OBJECTIVE

We aimed to evaluate the attitudes of doctors about cardiopulmonary resuscitation (CPR) in this research.

METHODS

Overall, 234 doctors who were working in Abant İzzet Baysal University Health Research and Application Center and who accepted to participate in this research were included. Research data were obtained by a questionnaire containing questions about demographic characteristics of doctors and their knowledge about CPR. Questionnaires were applied between 27.02.2012 and 04.06.2012. The chi-square test was used for categorical variables. A value of p<0.05 was considered statistically significant.

RESULTS

It was determined that 90% of the participants included in the study applied and/or observed CPR, and 62% of participants did not attend any CPR course. In addition, 64.1% of the doctors were found to be aware of guidelines prepared every 5 years. Although 65.2% of the doctors who attended a course previously gave a correct answer for the question about the number of cardiac compressions during adult CPR, 47.6% of the doctors who did not attend a course gave the correct answer (p=0.014). Additionally, 71.9% of participants who attended a course previously and 51.7% of participants who did not replied correctly to the question 'What should be done immediately after defibrillation during CPR?' And also the results for the question about how many joules is necessary to begin defibrillation with a monophasic defibrillator were statistically significant according to the attendance for a CPR course (p<0.005).

CONCLUSION

In this study, we have identified the lack of knowledge of the doctors about resuscitation.

[Inhospital resuscitation : Decisive measures for the outcome]

BACKGROUND

Approximately 18 million patients are treated in German hospitals annually. On the basis of internationally published data the number of in-hospital cardiac arrests can be estimated as 54,000 per year. A structured treatment of in-hospital resuscitation according to the current scientific evidence is essential.

AIM

In-hospital resuscitation shows some special characteristics in comparison to resuscitation in emergency services, which are highlighted in this article.

MATERIAL AND METHODS

This article is based on the international guidelines for cardiopulmonary resuscitation (CPR) first published in 1992 by the European Resuscitation Council (ERC) and the American Heart Association (AHA) as well as the amendments (current version 2010). Some current studies are also presented, which could not be taken into consideration for the guidelines from 2010.

RESULTS

High quality chest compressions with as few interruptions as possible are of utmost importance. Patients with cardiac rhythms which can be defibrillated should be defibrillated within less than 2 min after the collapse. There is no evidence that equipping hospitals with automated external defibrillators is an advantage for survival after in-hospital cardiac arrest. Endotracheal intubation represents the gold standard of airway management during CPR. During in-hospital resuscitation experienced anesthesiologists are mostly involved; however, the use of supraglottic airway devices may help to minimize interruptions in chest compressions especially before the medical emergency team arrives at the scene. Feedback devices may improve the quality of manual chest compressions; however, most devices overestimate the compression depth if the patient is resuscitated when lying in bed. There is no evidence that mechanical chest compression devices improve the outcome after cardiac arrest. Mild therapeutic hypothermia is still recommended for neuroprotection after successful in-hospital resuscitation.

CONCLUSION

The prevention of cardiac arrest is of special importance. Uniform and low threshold criteria for alarming the medical emergency team have to be defined to be able to identify and treat critically ill patients in time before cardiac arrest occurs.

Cardiopulmonary resuscitation knowledge and skills of registered nurses in Botswana

BACKGROUND

In Botswana nurses provide most health care in the primary, secondary and tertiary level clinics and hospitals. Trauma and medical emergencies are on the increase, and nurses should have cardiopulmonary resuscitation (CPR) knowledge and skills in order to be able to implement effective interventions in cardiac arrest situations.

OBJECTIVE

The objective of this descriptive study was to assess registered nurses’ CPR knowledge and skills.

METHOD

A pre-test, intervention and re-test time-series research design was adopted, and data were collected from 102 nurses from the 2 referral hospitals in Botswana. A multiple-choice questionnaire and checklist were used to collect data.

RESULTS

All nurses failed the pre-test. Their knowledge and skills improved after training, but deteriorated over the three months until the post-test was conducted.

CONCLUSION

The significantly low levels of registered nurses’ CPR skills in Botswana should be addressed by instituting country-wide CPR training and regular refresher courses

Using Simulation Education With Deliberate Practice to Teach Leadership and Resource Management Skills to Senior Resident Code Leaders

BACKGROUND

Cardiopulmonary arrests are rare, high-stakes events that benefit from using crisis resource management (CRM). Simulation-based education with deliberate practice can promote skill acquisition.

OBJECTIVE

We assessed whether using simulation-based education to teach CRM would lead to improved performance, compared to a lecture format.

METHODS

We tested third-year internal medicine residents in simulated code scenarios. Participants were randomly assigned to simulation-based education with deliberate practice (SIM) group or lecture (LEC) group. We created a checklist of CRM critical actions (which includes announcing the diagnosis, asking for help/suggestions, and assigning tasks), and reviewed videotaped performances, using a checklist of skills and communications patterns to identify CRM skills and communication efforts. Subjects were tested in simulated code scenarios 6 months after the initial assessment.

RESULTS

At baseline, all 52 subjects recognized distress, and 92% (48 of 52) called for help. Seventy-eight percent (41 of 52) did not succeed in resuscitating the simulated patient or demonstrate the CRM skills. After intervention, both groups (n  =  26 per group) improved. All SIM subjects announced the diagnosis compared to 65% LEC subjects (17 of 26, P  =  .01); 77% (20 of 26) SIM and 19% (5 of 26) LEC subjects asked for suggestions (P < .001); and 100% (26 of 26) SIM and 27% (7 of 26) LEC subjects assigned tasks (P < .001).

CONCLUSIONS

The SIM intervention resulted in significantly improved team communication and cardiopulmonary arrest management. During debriefing, participants acknowledged the benefit of the SIM sessions.

Institutional resuscitation protocols: do they affect cardiopulmonary resuscitation outcomes? A 6-year study in a single tertiary-care centre

PURPOSE

Despite advances in cardiopulmonary resuscitation and widespread life-support trainings, the outcomes of resuscitation are variable. There is a definitive need for organizational inputs to strengthen the resuscitation process. Our hospital authorities introduced certain changes at the organizational level in our in-house resuscitation protocol. We aimed to study the impact of these changes on the outcomes of resuscitation.

METHODS

The hospital code blue committee decided to reformulate the resuscitation protocols and reframe the code blue team. Various initiatives were taken in the form of infrastructural changes, procurement of equipment, organising certified training programs, conduct of mock code and simulation drills etc. A prospective and retrospective observational study was made over 6 years: a pre-intervention period, which included all cardiac arrests from January 2007 to December 2009, before the implementation of the program, and a post-intervention period from January 2010 to December 2012, after the implementation of the program. The outcomes of interest were response time, immediate survival, day/night survival and survival to discharge ratio.

RESULTS

2,164 in-hospital cardiac arrests were included in the study, 1,042 during the pre-intervention period and 1,122 during the post-intervention period. The survival percentage increased from 26.7 to 40.8 % (p < 0.05), and the survival to discharge ratio increased from 23.4 to 66.6 % (p < 0.05). Both day- and night-time survival improved (p < 0.05) and response time improved from 4 to 1.5 min.

CONCLUSIONS

A strong hospital-based resuscitation policy with well-defined protocols and infrastructure has potential synergistic effect and plays a big role in improving the outcomes of resuscitation.

Use of an electronic decision support tool improves management of simulated in-hospital cardiac arrest

INTRODUCTION

Adherence to advanced cardiac life support (ACLS) guidelines during in-hospital cardiac arrest (IHCA) is associated with improved outcomes, but current evidence shows that sub-optimal care is common. Successful execution of such protocols during IHCA requires rapid patient assessment and the performance of a number of ordered, time-sensitive interventions. Accordingly, we sought to determine whether the use of an electronic decision support tool (DST) improves performance during high-fidelity simulations of IHCA.

METHODS

After IRB approval and written informed consent was obtained, 47 senior medical students were enrolled. All participants were ACLS certified and within one month of graduation. Each participant was issued an iPod Touch device with a DST installed that contained all ACLS management algorithms. Participants managed two scenarios of IHCA and were allowed to use the DST in one scenario and prohibited from using it in the other. All participants managed the same scenarios. Simulation sessions were video recorded and graded by trained raters according to previously validated checklists.

RESULTS

Performance of correct protocol steps was significantly greater with the DST than without (84.7% v 73.8%, p<0.001) and participants committed significantly fewer additional errors when using the DST (2.5 errors vs. 3.8 errors, p<0.012).

CONCLUSION

Use of an electronic DST provided a significant improvement in the management of simulated IHCA by senior medical students as measured by adherence to published guidelines.

In-hospital cardiac arrest: can we change something?

Cardiac arrest is classified as 'in-hospital' if it occurs in a hospitalised patient who had a pulse at the time of admission. A probability of patient's survival until hospital discharge is very low. The reasons for this are old age, multiple co-morbidity of patients, late recognition of cardiac arrest, poor knowledge about basic life support algorithm, insufficient equipment, absence of qualified resuscitation teams (RTs) and poor organization.The aim of this study was to demonstrate characteristics of in-hospital cardiac arrests and resuscitation measures in University Hospital Osijek. We analysed retrospectively all resuscitation procedures data where anaesthesiology RTs provided cardiopulmonary resuscitation (CPR) during 5-year period.We analysed 309 in-hospital resuscitation attempts with complete documentation. Victims of cardiac arrest were principally elderly patients, neurological (30.4 %), surgical (25.24 %) and neurosurgical patients (15.2 %) with many associated severe diseases. In 85.6 % of the cases, resuscitation was initiated by ward personnel and RTs arrived within 5 min in 67 % of the cases. However, in 14.6 % of the cases resuscitation measures had not been started before RT arrival. We found statistical correlation between lower initial survival rates and length of hospital stay (p = 0.001), presence of cerebral ischemia (p = 0.026) or cardiomyopathy (p = 0.004) and duration of CPR (p = 0.041). Initial survival was very low (14.6 %), and full recovery was accomplished in only eight patients out of 309 (2.59 %).Identification of terminal chronic patients in which the CPR is not reasonable, a better organisation and ward personnel education can contribute to better overall success.

Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association

The "2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" increased the focus on methods to ensure that high-quality cardiopulmonary resuscitation (CPR) is performed in all resuscitation attempts. There are 5 critical components of high-quality CPR: minimize interruptions in chest compressions, provide compressions of adequate rate and depth, avoid leaning between compressions, and avoid excessive ventilation. Although it is clear that high-quality CPR is the primary component in influencing survival from cardiac arrest, there is considerable variation in monitoring, implementation, and quality improvement. As such, CPR quality varies widely between systems and locations. Victims often do not receive high-quality CPR because of provider ambiguity in prioritization of resuscitative efforts during an arrest. This ambiguity also impedes the development of optimal systems of care to increase survival from cardiac arrest. This consensus statement addresses the following key areas of CPR quality for the trained rescuer: metrics of CPR performance; monitoring, feedback, and integration of the patient's response to CPR; team-level logistics to ensure performance of high-quality CPR; and continuous quality improvement on provider, team, and systems levels. Clear definitions of metrics and methods to consistently deliver and improve the quality of CPR will narrow the gap between resuscitation science and the victims, both in and out of the hospital, and lay the foundation for further improvements in the future.

Evolution of the Pediatric Advanced Life Support course: enhanced learning with a new debriefing tool and Web-based module for Pediatric Advanced Life Support instructors

OBJECTIVE

To describe the history of the Pediatric Advanced Life Support course and outline the new developments in instructor training that will impact the way debriefing is conducted during Pediatric Advanced Life Support courses.

OUTLINE

The Pediatric Advanced Life Support course, first released by the American Heart Association in 1988, has seen substantial growth and change over the past few decades. Over that time, Pediatric Advanced Life Support has become the standard for resuscitation training for pediatric healthcare providers in North America. The incorporation of high-fidelity simulation-based learning into the most recent version of Pediatric Advanced Life Support has helped to enhance the realism of scenarios and cases, but has also placed more emphasis on the importance of post scenario debriefing. We developed two new resources: an online debriefing module designed to introduce a new model of debriefing and a debriefing tool for real-time use during Pediatric Advanced Life Support courses, to enhance and standardize the quality of debriefing by Pediatric Advanced Life Support instructors. In this article, we review the history of Pediatric Advanced Life Support and Pediatric Advanced Life Support instructor training and discuss the development and implementation of the new debriefing module and debriefing tool for Pediatric Advanced Life Support instructors.

CONCLUSION

The incorporation of the debriefing module and debriefing tool into the 2011 Pediatric Advanced Life Support instructor materials will help both new and existing Pediatric Advanced Life Support instructors develop and enhance their debriefing skills with the intention of improving the acquisition of knowledge and skills for Pediatric Advanced Life Support students.

Impact of advanced cardiac life support training program on the outcome of cardiopulmonary resuscitation in a tertiary care hospital

Background:

Guidelines on performing cardiopulmonary resuscitation (CPR) have been published from time to time, and formal training programs are conducted based on these guidelines. Very few data are available in world literature highlighting the impact of these trainings on CPR outcome.

Aim:

The aim of our study was to evaluate the impact of the American Heart Association (AHA)-certified basic life support (BLS) and advanced cardiac life support (ACLS) provider course on the outcomes of CPR in our hospital.

Materials and Methods:

An AHA-certified BLS and ACLS provider training programme was conducted in our hospital in the first week of October 2009, in which all doctors in the code blue team and intensive care units were given training. The retrospective study was performed over an 18-month period. All in-hospital adult cardiac arrest victims in the pre-BLS/ACLS training period (January 2009 to September 2009) and the post-BLS/ACLS training period (October 2009 to June 2010) were included in the study. We compared the outcomes of CPR between these two study periods.

Results:

There were a total of 627 in-hospital cardiac arrests, 284 during the pre-BLS/ACLS training period and 343 during the post-BLS/ACLS training period. In the pre-BLS/ACLS training period, 52 patients (18.3%) had return of spontaneous circulation, compared with 97 patients (28.3%) in the post-BLS/ACLS training period (P < 0.005). Survival to hospital discharge was also significantly higher in the post-BLS/ACLS training period (67 patients, 69.1%) than in the pre-BLS/ACLS training period (12 patients, 23.1%) (P < 0.0001).

Conclusion:

Formal certified BLS and ACLS training of healthcare professionals leads to definitive improvement in the outcome of CPR.

Annual resuscitation competency assessments: a review of the evidence

BACKGROUND

Australian critical care nurses generally undertake assessment of resuscitation competencies on an annual or biannual basis. International resuscitation evidence and guidelines released in 2010 do not support this practice, instead advocating more frequent retraining.

AIM

To review the evidence for annual assessment of resuscitation knowledge and skills, and for the efficacy of resuscitation training practices.

METHODS

A search of the Medline and CINAHL databases was conducted using the key search words/terms 'resuscitation' 'advanced life support' 'advanced cardiac life support' 'assessment' 'cardiac arrest', 'in-hospital cardiac arrest', 'competence', 'training', 'ALS', 'ACLS' 'course' and 'competency'. The search was limited to English language publications produced during the last 10 years. The International Liaison Committee On Resuscitation worksheets were reviewed for key references, as were the reference lists of articles from the initial search.

RESULTS

There is little evidence to support the current practice of annual resuscitation competency assessments. Theoretical knowledge has no correlation with resuscitation performance, and current practical assessment methods are problematic. Both knowledge and skills decline well before the 12-month mark. There is emerging support in the literature for frequent practice sessions using simulation technology.

CONCLUSION

The current practice of annual assessments is not supported by evidence. Emerging evidence for regular resuscitation practice is not conclusive, but it is likely to produce better outcomes. Changing practice in Australia also represents an opportunity to generate data to inform practice further.

Collaboration between Civilian and Military Healthcare Professionals: A Better Way for Planning, Preparing, and Responding to All Hazard Domestic Events

Collaboration is used by the US National Security Council as a means to integrate inter-federal government agencies during planning and execution of common goals towards unified, national security. The concept of collaboration has benefits in the healthcare system by building trust, sharing resources, and reducing costs. The current terrorist threats have made collaborative medical training between military and civilian agencies crucial.

This review summarizes the long and rich history of collaboration between civilians and the military in various countries and provides support for the continuation and improvement of collaborative efforts. Through collaboration, advances in the treatment of injuries have been realized, deaths have been reduced, and significant strides in the betterment of the Emergency Medical System have been achieved. This review promotes collaborative medical training between military and civilian medical professionals and provides recommendations for the future based on medical collaboration.

Knowledge of Iranian medical interns regarding cardio-pulmonary resuscitation

Objectives:

Cardio-Pulmonary Resuscitation (CPR) is one of the most important procedures in emergency medicine. As new trends are evolving in medical education , we planned to evaluate the interests and knowledge of medical students regarding educational methods in CPR learning.

Materials and Methods:

In a cross-sectional analytical descriptive study, a standardized questionnaire was distributed among 180 medical interns at the Mashhad University of Medical Sciences. The questionnaire had three parts: demographics, general questions, and CPR knowledge. If they had more than 10 correct answers (out of 15) in knowledge, they were placed in group A and if more than 5, in group B and correct answers less than 5 were categorized in group C.

Results:

159 interns filled the questionnaires. Mean age was 24.99 ± 0.96 and 56.5% were female; 52.7% were educated only theoretically and 47.3% had combined theoretical and clinical knowledge; male interns were significantly more educated (P = 0.041). Residents were the majority of trainers (56.8%) and only 14.3% were educated by the staffs. Only 7% mentioned that they felt they could do a complete CPR and 37.3% considered themselves as assistants; 93.7% believed that isolated emergency ward and teaching courses were needed for better education and 95% declared that continuous education is obligatory; 33.5% were in group A and 45.8% were in group B.

Conclusions:

CPR education is of interest to most interns. Due to lack of emergency medicine wards and, the interns’ knowledge and their practical skills were insufficient to perform acceptable CPR.

Does training learners on simulators benefit real patients?

Despite limited data on patient outcomes, simulation training has already been adopted and embraced by a large number of medical schools. Yet widespread acceptance of simulation should not relieve us of the duty to demonstrate if, and under which circumstances, training learners on simulation benefits real patients. Here we review the data on performance of healthcare providers or trainees following simulation training, and discuss ways of enhancing transfer of learning from simulated to real patients. While there is tremendous potential for simulation in medical education and healthcare, further studies are needed to identify if and when simulation training improves the quality of care delivered to patients, and to compare the cost-effectiveness of simulated learning experiences to lower fidelity and less expensive interventions.

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.

What is the impact of structured resuscitation training on healthcare practitioners, their clients and the wider service? A BEME systematic review: BEME Guide No. 20

A large number of resuscitation training courses (structured resuscitation training programmes (SRT)) take place in many countries in the world on a regular basis. This review aimed to determine whether after attending SRT programmes, the participants have a sustained retention of resuscitation knowledge and skills after their initial acquisition and whether there is an improvement in outcome for patients and/or their healthcare organisation after the institution of an SRT programme. All research designs were included, and the reported resuscitation training had to have been delivered in a predefined structured manner over a finite period of time. Data was extracted from the 105 eligible articles and research outcomes were assimilated in tabular form with qualitative synthesis of the findings to produce a narrative summary. Findings of the review were: SRTs result in an improvement in knowledge and skills in those who attend them, deterioration in skills and, to a lesser extent, knowledge is highly likely as early as three months following SRTs, booster or refresher sessions may improve an individual's ability to retain resuscitation skills after initial training and the instigation of resuscitation training in a healthcare institution significantly improves clinical management of resuscitations and patient outcome (including survival) after resuscitation attempts.

Theoretical knowledge of nurses working in non-hospital urgent and emergency care units concerning cardiopulmonary arrest and resuscitation

Non-Hospital Urgent and Emergency Care Units were created to deliver care to patients in chronic or acute situations and to coordinate the flow of urgent care. This descriptive study analyzed the theoretical knowledge of nurses working in these units concerning cardiopulmonary arrest and resuscitation. A questionnaire was applied to 73 nurses from 16 units in seven cities in the region of Campinas, SP, Brazil. The respondents displayed some gaps in their knowledge such as how to detect Cardiopulmonary Arrest (CPA), the ability to list the sequence of basic life support, and how to determine the appropriate compression to ventilation ratio (>60%). They also did not know: the immediate procedures to take after CPA detection (>70%); the rhythm pattern present in a CPA (>80%); and they only partially identified (100%) the medication used in cardiopulmonary resuscitation. The average score on a scale from zero to ten was 5.2 (± 1.4). The nurses presented partial knowledge of the guidelines available in the literature.

The effectiveness of high fidelity simulation on medical-surgical registered nurses' ability to recognise and respond to clinical emergencies

BACKGROUND

There is a paucity of evidence regarding the efficacy in preparing medical-surgical nurses to respond to patients with acutely deteriorating conditions.

STUDY AIM

The aim of this study was to evaluate registered nurses' ability to respond to the deteriorating patient in clinical practise following training using immersive simulation and use of a high fidelity simulator.

METHODS

This study was a follow-up survey of medical-surgical graduate nurses following immersive high fidelity simulation training. Thirty eight registered nurses practising in medical-surgical areas completed the simulation as part of university graduate study. A follow-up survey of the graduate medical-surgical registered nurses conducted three months following completion of a high fidelity simulation-based learning experience. Outcomes consisted of the number of times skills were used in practise and the usefulness of simulation in preparing for actual emergency events.

RESULTS

Participants reported a total of 164 clinical patient emergencies in the follow-up time period including: 46% cardiac, 32% respiratory, 10% neurological, 7% cardiac arrest and 5% related to electrolyte disturbances. The ability to respond in a systematic way, handover to the emergency team and airway management were identified as the skills most improved during patient emergencies following simulation. The most useful aspects of the simulation experience identified were scenario debriefing and assertiveness training. Participants with less years of clinical experience were more likely to report practising the team leader role and debriefing as the most useful aspects of simulation.

CONCLUSIONS

The skills practised in simulation were highly relevant to participants practise in medical-surgical areas. Non-technical skills, including assertiveness skills should be considered in future emergency training courses for nurses.

ICU nurses' perceptions of potential constraints and anticipated support to practice defibrillation: a qualitative study

AIM

The study examines the experience of intensive care nurses in caring for patients in cardiac arrest, and their perceptions of introducing nurse-led defibrillation.

METHOD

This was a descriptive, exploratory and qualitative study at an intensive care unit (ICU) of an acute regional hospital in Hong Kong. Twelve registered nurses were purposefully selected for interview.

RESULTS

Although all the participants were trained in basic life support, only 50% were trained in advanced cardiac life support (ACLS), and those trained in ACLS described having limited opportunities to apply their defibrillation knowledge. Whilst participants believed that they were theoretically prepared to influence the patient's resuscitation outcomes, newly qualified nurses were reluctant to be accountable for defibrillation. In contrast, experienced nurses were more willing to perform nurse-led defibrillation. Support from management, cooperation between nurses and doctors, regular in-hospital 'real-drill' programmes, sponsorship for training, and the use of alternative defibrillation equipment should be considered to encourage nurse-led defibrillation in ICU settings.

CONCLUSION

Nurse-led defibrillation is an approach of delivering prompt care to critically ill patients, and a way ahead for intensive care nursing in Hong Kong. Emphasis on a consistent policy to promote nurse-led defibrillation practice is needed.