Trends in use of intraosseous and intravenous access in out-of-hospital cardiac arrest across English ambulance services: A registry-based, cohort study

INTRODUCTION

The optimum route for drug administration in cardiac arrest is unclear. Recent data suggest that use of the intraosseous route may be increasing. This study aimed to explore changes over time in use of the intraosseous and intravenous drug routes in out-of-hospital cardiac arrest in England.

METHODS

We extracted data from the UK Out-of-Hospital Cardiac Arrest Outcomes registry. We included adult out-of-hospital cardiac arrest patients between 2015-2020 who were treated by an English Emergency Medical Service that submitted vascular access route data to the registry. The primary outcome was any use of the intraosseous route during cardiac arrest. We used logistic regression models to describe the association between time (calendar month) and intraosseous use.

RESULTS

We identified 75,343 adults in cardiac arrest treated by seven Emergency Medical Service systems between January 2015 and December 2020. The median age was 72 years, 64% were male and 23% presented in a shockable rhythm. Over the study period, the percentage of patients receiving intraosseous access increased from 22.8% in 2015 to 42.5% in 2020. For each study-month, the odds of receiving any intraosseous access increased by 1.019 (95% confidence interval 1.019 to 1.020, p < 0.001). This observed effect was consistent across sensitivity analyses. We observed a corresponding decrease in use of intravenous access.

CONCLUSION

In England, the use of intraosseous access in out-of-hospital cardiac arrest has progressively increased over time. There is an urgent need for randomised controlled trials to evaluate the clinical effectiveness of the different vascular access routes in cardiac arrest.

Medical leadership training varies substantially between UK medical schools: Report of the leadership in undergraduate medical education national survey (LUMENS)

BACKGROUND

Doctors are increasingly expected to demonstrate medical leadership and management (MLM) skills. The Faculty of Medical Leadership and Management (FMLM) has published an indicative undergraduate curriculum to guide the development of MLM content at UK medical schools.

METHOD

Students from 30 medical schools were surveyed to determine their understanding of MLM teaching at their school. Timetables for 21 schools were searched for MLM-related keywords. Student-reported teaching and timetabled teaching were coded according to predefined themes. Aggregated demographic and postgraduate performance data were obtained through collaboration with the Medical Student Investigators Collaborative (msico.org).

RESULTS

Whilst 88% of medical students see MLM teaching as relevant, only 18% believe it is well integrated into their curriculum. MLM content represented ∼2% of timetabled teaching in each 5-year undergraduate medical course. Most of this teaching was dedicated to teamwork, performance/reflection and communication skills. There was minimal association between how much of a topic students believed they were taught, and how much they were actually taught. We found no association between the volume of MLM teaching and performance in postgraduate examinations, trainee career destinations or fitness to practice referrals.

CONCLUSION

Our findings demonstrate limited and variable teaching of MLM content. Delivery was independent of broader teaching and assessment factors.

Improving paediatric flow in an UK Paediatric Assessment Unit

The 2010 Royal College of Paediatrics and Child Health (RCPCH) guidelines for acute paediatric services set standards for time to senior review for paediatric medical admissions in the UK as tier two doctor (registrar) review within 4 hours and consultant review within 14 hours. Our aim was to implement these standards in our unit through increasing proportions of reviews within these timeframes and measuring the impact on patient flow. Four quality improvement cycles were completed between March 2018 and March 2020 capturing data from 288 patient data sets. Recommendations included the extension of consultant on-site availability out of routine working hours (after cycle 1), highlighting patients awaiting consultant review during team handover (after cycle 2), and improving tier two doctor rostering (after cycle 3). After highlighting patients for consultant priority review, the proportion of patients seen within 14 hours improved from 53.3% (cycle 2) to 95% (cycle 3, p=0.005). Improved tier two doctor cover increased the proportion meeting registrar review within 4 hours from 82.9% (cycle 3) to 96.2% (cycle 4, p=0.028). A large proportion of paediatric patients were managed and discharged at tier two doctor level (65.6% over cycles 1–4). An inverse correlation was seen (R=−0.587) between time to discharge and the number of tier two doctors on shift (cycle 4). The interventions conducted demonstrated significant improvement in proportions of paediatric patients seen within the RCPCH timeframes. Adequate tier two doctor staffing is a priority for prompt review and discharge of acute paediatric patients. Future work aims to consider factors such as nursing rostering, bed management and the impact of COVID-19 on paediatric flow.

Antenatal determination of fetal brain activity in response to an acoustic stimulus using functional magnetic resonance imaging

Functional magnetic resonance imaging (fMRI) is now a well-established technique for directly identifying adult brain activity. This study builds on earlier pilot work that showed that fMRI could provide direct evidence of fetal brain cortical activation in response to an auditory stimulus. The new work presented here aims to assess the sensitivity of this technique in a larger sample group. This article includes a specific discussion of the methodology required for fetal fMRI. Sixteen pregnant subjects were scanned between 37 and 41 weeks gestation, 12 had an auditory stimulus applied to the maternal abdomen (study group) and 4 had an auditory stimulus applied to the mother's ears (control group). Two of twelve (2/12) study-group patients experienced back pain so that the experiment was abandoned; 4/12 showed significant activation (P < 0.005) in one or both of the temporal lobes; 1/12 showed significant activation in the frontal lobe. A susceptibility artifact at the interface between the maternal bowel and the fetus affected 3/12 data sets. No significant activation was found in 3/4 of the control cases, and 1/4 could not be analyzed due to a susceptibility artifact.

Antenatal determination of fetal brain activity in response to an acoustic stimulus using functional magnetic resonance imaging

Functional magnetic resonance imaging (fMRI) is now a well-established technique for directly identifying adult brain activity. This study builds on earlier pilot work that showed that fMRI could provide direct evidence of fetal brain cortical activation in response to an auditory stimulus. The new work presented here aims to assess the sensitivity of this technique in a larger sample group. This article includes a specific discussion of the methodology required for fetal fMRI. Sixteen pregnant subjects were scanned between 37 and 41 weeks gestation, 12 had an auditory stimulus applied to the maternal abdomen (study group) and 4 had an auditory stimulus applied to the mother's ears (control group). Two of twelve (2/12) study-group patients experienced back pain so that the experiment was abandoned; 4/12 showed significant activation (P < 0.005) in one or both of the temporal lobes; 1/12 showed significant activation in the frontal lobe. A susceptibility artifact at the interface between the maternal bowel and the fetus affected 3/12 data sets. No significant activation was found in 3/4 of the control cases, and 1/4 could not be analyzed due to a susceptibility artifact.

Prenatal diagnosis of congenital Wilms' tumor (nephroblastoma) presenting as fetal hydrops

We describe a case of congenital nephroblastoma (Wilms' tumor) presenting at 28 weeks of gestation with fetal hydrops and polyhydramnios. Prenatal diagnosis was made by biopsy. An emergency Cesarean section was performed due to deterioration in the cardiotocograph. A post-mortem examination confirmed the diagnosis of congenital nephroblastoma.