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Interdisciplinary ICU Cardiac Arrest Debriefing Improves Survival Outcomes
Abstract
In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events.
Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU.
Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers.
Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed "excellent cardiopulmonary resuscitation," prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ≤ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91-6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01-7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9-10.6; p < 0.01).
Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.
... Despite following these guidelines, research suggests that CPR quality remains suboptimal with poor outcomes in many hospitals [6,7]. Over the past few decades, various quality improvement (QI) interventions have been implemented and individually assessed for optimizing CPR performances and reducing mortality rates [8,9]. However, the data are still limited. ...
... However, the data are still limited. Debriefng after CPR events has been associated with improved quality of CPR and survival after IHCA [9]. It ofers an opportunity to identify and address the critical event comprehensively improving the overall resuscitation team performance [9]. ...
... Debriefng after CPR events has been associated with improved quality of CPR and survival after IHCA [9]. It ofers an opportunity to identify and address the critical event comprehensively improving the overall resuscitation team performance [9]. We aimed to assess the efectiveness of a qualitative improvement (QI) bundle (hands-on training and debriefng) on compliance with AHA resuscitation guidelines during IHCA in our children's hospital. ...
Introduction:
Various quality improvement (QI) interventions have been individually assessed for the quality of cardiopulmonary resuscitation (CPR). We aimed to assess the QI bundle (hands-on training and debriefing) for the quality of CPR in our children's hospital. We hypothesized that the QI bundle improves the quality of CPR in hospitalized children.
Methods:
We initiated a QI bundle (hands-on training and debriefing) in August 2017. We conducted a before-after analysis comparing the CPR quality during July 2013-May 2017 (before) and January 2018-December 2020 (after). We collected data from the critical events logbook on CPR duration, chest compressions (CC) rate, ventilation rate (VR), the timing of first dose of epinephrine, blood pressure (BP), end-tidal CO2 (EtCO2), and vital signs monitoring during CPR. We performed univariate analysis and presented data as the median interquartile range (IQR) and in percentage as appropriate.
Results:
We compared data from 58 CPR events versus 41 CPR events before and after QI bundle implementation, respectively. The median (IQR) CPR duration for the pre- and post-QI bundle was 5 (1-13) minutes and 3 minutes (1.25-10), and the timing of the first dose of epinephrine was 2 (1-2) minutes and 2 minutes (1-5), respectively. We observed an improvement in compliance with the CC rate (100-120 per minute) from 72% events before versus 100% events after QI bundle implementation (p=0.0009). Similarly, there was a decrease in CC interruptions and hyperventilation rates from 100% to 50% (p=0.016) and 100% vs. 63% (p=<0.0001) events before vs. after QI bundle implementation, respectively. We also observed improvement in BP monitoring from 36% before versus 60% after QI bundle (p=0.014).
Conclusion:
Our QI bundle (hands-on training and debriefing) was associated with improved compliance with high-quality CPR in children.
... In the heart, DMF prevented fragmentation of the mitochondrial network and maintained myocardial ultrastructure, the significance of which remains to be elucidated in future studies. We chose to evaluate the effect of DMF on mitochondrial health in a pediatric porcine model of asphyxida-induced IHCA because respiratory deterioration accounts for 42-52% of all pediatric cases of IHCA [4][5][6][7][8][9]55,77 . The induction of VF allowed us not only to provide and standardize high-quality CPR and post-arrest care to enhance the probability to detect changes in response to DMF treatment but also holds significant relevance for the clinical setting with almost one-third of all IHCA cases presenting with VF during CPR 36,78 . ...
... We used a previously published pediatric porcine model of IHCA 59 , which simulates an asphyxial event followed by VF. Respiratory deterioration accounts for 42-52% of all pediatric cases of IHCA [4][5][6][7][8][9]77 . Furthermore, VF is a frequent event during IHCA, accounting for almost one-third of all IHCA cases, and therefore holds significant relevance for CA in children in the clinical setting. ...
Neurological and cardiac injuries are significant contributors to morbidity and mortality following pediatric in-hospital cardiac arrest (IHCA). Preservation of mitochondrial function may be critical for reducing these injuries. Dimethyl fumarate (DMF) has shown potential to enhance mitochondrial content and reduce oxidative damage. To investigate the efficacy of DMF in mitigating mitochondrial injury in a pediatric porcine model of IHCA, toddler-aged piglets were subjected to asphyxia-induced CA, followed by ventricular fibrillation, high-quality cardiopulmonary resuscitation, and random assignment to receive either DMF (30 mg/kg) or placebo for four days. Sham animals underwent similar anesthesia protocols without CA. After four days, tissues were analyzed for mitochondrial markers. In the brain, untreated CA animals exhibited a reduced expression of proteins of the oxidative phosphorylation system (CI, CIV, CV) and decreased mitochondrial respiration (p < 0.001). Despite alterations in mitochondrial content and morphology in the myocardium, as assessed per transmission electron microscopy, mitochondrial function was unchanged. DMF treatment counteracted 25% of the proteomic changes induced by CA in the brain, and preserved mitochondrial structure in the myocardium. DMF demonstrates a potential therapeutic benefit in preserving mitochondrial integrity following asphyxia-induced IHCA. Further investigation is warranted to fully elucidate DMF’s protective mechanisms and optimize its therapeutic application in post-arrest care.
... Copeland und Liska [4] legten dar, dass die Beteiligten durch die Umsetzung einer Nachbesprechung 24 h nach der Reanimation weniger Sorgen und Gedanken äußerten. Außerdem können arbeitsbezogene Prozesse [4] und die Reanimationsqualität [19] verbessert werden. Berchtenbreiter et al. [3] ...
... Möglich ist in diesem Fall die spätere Durchführung des Debriefings als sog. Cold-Debriefing [5,19]. ...
In the context of medical care, healthcare professionals are confronted with cardiopulmonary resuscitation, which can have long-term effects on the participants.
The aim was to develop, implement, and evaluate a protocol-supported post-resuscitation talk for practice in the intensive care unit of a university hospital.
Within the evidence-based nursing working group, university-qualified nurses performed a systematic literature search in CareLit (hpsmedia, Hungen, Germany), the Cochrane Library (Cochrane, London, England), LIVIVO (Deutsche Zentralbibliothek für Medizin, Cologne, Germany), and PubMed/MEDLINE (U.S. National Library of Medicine, Bethesda, MD, USA) as well as using the snowball principle. Based on the results, the post-resuscitation talk and a debriefing protocol were developed and consented in a multiprofessional team. Additionally, a questionnaire to analyze the current situation (t0) and evaluate the implementation (t1) was developed.
Implementation of the post-resuscitation talk was conducted from August 2021. The t0 survey took place from June to July 2021 and for t1 from February to March 2022. In t0, fewer interprofessional reflections were carried out after resuscitations in the category always or frequently (17.5%, n = 7) than in t1 (50.0%, n = 13). The rate of initiated improvement interventions was increased (t0: 24.3%, n = 9 vs. t1: 59.1%, n = 13). The results show promotion of multiprofessional collaboration in t0 and t1, and potential for optimization in the debriefing protocol in t1.
Implementation of a post-resuscitation talk in hospitals is a useful tool for the structured interprofessional follow-up of resuscitation events. The results demonstrated initial positive effects and potential for optimization.
... Resuscitation teams often struggle to achieve key tasks in a timely fashion, further contributing to poor outcomes from cardiac arrest [3]. Debriefing has been shown to improve provider performance and patient outcomes from cardiac arrest [4,5]. High-quality data from both real and simulated resuscitation event can help inform performance and area of improvement during the debriefing of critical event [6]. ...
... Paper charting is time-consuming and error prone, which explained its inefficiency during medical care. Inaccuracy of clinical data collected from resuscitation events represents a potential lost opportunity to improve provider performance, particularly when data-informed debriefing has proven benefits in improving cardiac arrest outcomes [4,6]. ...
To determine if data collected through digital charting are more complete and more accurate compared to traditional paper-based charting during simulated pediatric cardiac arrest.
We performed a single-center simulation-based randomized controlled trial. Participants were randomized to a novel handheld digital charting device (intervention group) or to the standard resuscitation paper chart (control group). Participants documented two 15-min simulated pediatric cardiac arrest scenarios. We compared the charting completeness between the two groups. Completeness score (primary outcome) was established by calculating a completeness score for each group based on a list of pre-determined critical tasks. Charting accuracy (secondary outcome) was compared between the two groups, defined as the time interval between the real-time task performance and charted time.
Charting data from 34 simulated cardiac arrest events were included in the analysis (n = 18 intervention; n = 16 control). The paper charting group had a higher completeness score (median (IQR) paper vs digital: 72.0% (66.4–76.9%) vs 65.0% (58.5–66.4%), p = 0.015). For accuracy, the digital charting group was superior to the paper charting group for all pre-established critical tasks.
Compared to paper-based charting, digital charting group captured more critical tasks during pediatric simulated resuscitation and was more accurate in the time intervals between real-time tasks performance and charted time. For tasks charted, paper-based charting was significantly more complete and more detailed during simulated pediatric cardiac arrest.
... [1][2][3][4][5] Provision of high quality, guideline-compliant CPR improves hemodynamics and is directly associated with improved patient outcomes. [6][7][8][9][10][11][12] Despite the proven importance of high-quality CPR, trained healthcare providers have consistently demonstrated an inability to perform effective chest compressions (CC) in both simulated and real CPA. [13][14][15][16][17][18][19][20] In a series of studies from a single institution, Sutton et al. describe how pediatric providers struggle to deliver guidelinecompliant CPR during pediatric CPA. ...
... 20 The use of two interventions, real-time CPR feedback during CPA, and Just-in-Time (JIT) training (with real-time CPR feedback during practice), have demonstrated improved quality of CPR during practice, 19,21,22 simulated CPA 18,20,23,24 and real pediatric CPA. 11,12,16,17,23,24 Despite the growing body of supportive evidence, no studies to date have described the variability in the impact of these 2 interventions on quality of CPR across multiple pediatric institutions. Variable impact of these interventions across institutions may indicate the need for implementation strategies that are tailored to the pattern of performance deficits identified amongst individuals or within specific institutions. ...
Aim: The variability in quality of CPR provided during cardiac arrest across pediatric institutions is unknown. We aimed to describe the degree of variability in the quality of CPR across 9 pediatric institutions , and determine if variability across sites would be affected by Just-in-Time CPR training and/or visual feedback during simulated cardiac arrest. Methods: We conducted secondary analyses of data collected from a prospective, multi-center trial. Participants were equally randomized to either: (1) No intervention; (2) Real-time CPR visual feedback during cardiac arrest or (3) Just-in-Time CPR training. We report the variability in median chest compression depth and rate across institutions, and the variability in the proportion of 30-s epochs of CPR meeting 2010 American Heart Association guidelines for depth and rate. Abbreviations: ACLS, advanced cardiac life support; AHA, American Heart Association; BLS, basic life support; CPA, cardiopulmonary arrest; CPR, cardiopulmonary resuscitation; CC, chest compressions; CCF, chest compression fraction; JIT, Just-in-Time; PALS, pediatric advanced life support. ଝ A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx. Results: We analyzed data from 528 epochs in the no intervention group, 552 epochs in the visual feedback group, and 525 epochs in the JIT training group. In the no intervention group, compression depth (median range 22.2-39.2 mm) and rate (median range 116.0-147.6 min −1) demonstrated significant variability between study sites (p < 0.001). The proportion of compressions with adequate depth (0-11.5%) and rate (0-60.5%) also varied significantly across sites (p < 0.001). The variability in compression depth and rate persisted despite use of real-time visual feedback or JIT training (p < 0.001). Conclusion: The quality of CPR across multiple pediatric institutions is variable. Variability in CPR quality across institutions persists even with the implementation of a Just-in-Time training session and visual feedback for CPR quality during simulated cardiac arrest.
... CPR quality metrics, time to defibrillation) collected during the cardiac arrest event have been associated with improved survival outcomes from pediatric cardiac arrest. 16,17 Unfortunately, postevent debriefings are infrequently conducted in most institutions, and when conducted, objective data is rarely used to support these conversations. 18,19 As a result, resuscitations teams are forced to rely upon provider recall of resuscitation events, which is often flawed and inaccurate, 20,21 to frame their discussions during debriefings. ...
... Compared to control group, the time to critical interventions metrics in the data-informed debriefing group were decreased, but the differences were not statistically significant for time to initiate CPR (control vs intervention: 16 Table 3). ...
Aim:
To determine if data-informed debriefing, compared to a traditional debriefing, improves the process of care provided by healthcare teams during a simulated pediatric cardiac arrest.
Methods:
We conducted a prospective, randomized trial. Participants were randomized to a traditional debriefing or a data-informed debriefing supported by a debriefing tool. Participant teams managed a 10-minute cardiac arrest simulation case, followed by a debriefing (i.e. traditional or data-informed), and then a second cardiac arrest case. The primary outcome was the percentage of overall excellent CPR. The secondary outcomes were compliance with AHA guidelines for depth and rate, chest compression (CC) fraction, peri-shock pause duration, and time to critical interventions.
Results:
A total of 21 teams (84 participants) were enrolled, with data from 20 teams (80 participants) analyzed. The data-informed debriefing group was significantly better in percentage of overall excellent CPR (control vs intervention: 53.8% vs 78.7%; MD 24.9%, 95%CI: 5.4 to 44.4%, p = 0.02), guideline-compliant depth (control vs. intervention: 60.4% vs 85.8%, MD 25.4%, 95%CI: 5.5 to 45.3%, p = 0.02), CC fraction (control vs intervention: 88.6% vs 92.6, MD 4.0%, 95%CI: 0.5 to 7.4%, p = 0.03), and peri-shock pause duration (control vs intervention: 5.8 s vs 3.7 s, MD -2.1 s, 95%CI: -3.5 to -0.8 s, p = 0.004) compared to the control group. There was no significant difference in time to critical interventions between groups.
Conclusion:
When compared with traditional debriefing, data-informed debriefing improves CPR quality and reduces pauses in CPR during simulated cardiac arrest, with no improvement in time to critical interventions.
... [798][799][800][801][802][803] Studies assessing the impact of debriefing after cardiac arrest events demonstrate improved provider performance, 804,805 while debriefings informed by clinical data have been associated with enhanced survival outcomes from cardiac arrest. 806,807 Many different debriefing frameworks have been developed and implemented, leading to variability in how debriefing is conducted across programs and institutions. 808 Debriefing scripts and tools have been developed to help standardize the approach to debriefing during resuscitation training. ...
This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.
... CED improves healthcare team performance and patient outcomes. [2][3][4][5] Multiple professional organizations recommend CED. [6][7][8] Effective CED leadership in the emergency department (ED) requires encouraging the reflection and participation of team members in a short period of time. ...
Objectives
Clinical event debriefing (CED) improves healthcare team performance and patient outcomes. Most pediatric emergency medicine (PEM) physicians do not receive formal training in leading CED. Our objectives were to develop a CED curriculum and evaluate its effect on performance, knowledge, comfort, and clinical practice.
Methods
This was a single group pre-post-retention study. We developed a hybrid curriculum with simulation, an interactive module, and individual feedback. We invited faculty and fellows from the PEM division of our hospital to participate. During an in-person training day, participants led standardized clinical simulation scenarios followed by simulated CED with immediate feedback on their leadership performance. They watched an interactive module between scenarios. Participants returned for a retention assessment 2–6 months later with a third simulation and debrief. Participants completed surveys measuring attitudes, experiences, and knowledge. Participants also evaluated the curriculum.
The primary outcome was CED leadership performance using a novel 21-item tool that we developed, the Debrief Leadership Tool for Assessment (DELTA). A blinded, trained rater measured performance with DELTA. Secondary outcomes included changes in knowledge and comfort and changes in clinical practice.
Results
Twenty-seven participants enrolled and completed all parts of the curriculum and assessments. Debrief leadership performance improved by a mean of 3.7 points on DELTA pre-training to post-training (95% confidence interval = 2.7, 4.6, P < 0.01) and by 1.4 points from pre-training to retention (95% confidence interval = 0.1, 2.8, P = 0.03). Knowledge and comfort also significantly improved from pre-training to post-training and were sustained at retention. Most (67%) participants changed their clinical practice of CED after completing the curriculum. All participants would recommend the training to other PEM physicians.
Conclusions
A hybrid simulation-based curriculum in leading CED for PEM physicians was associated with improvement in CED leadership performance, knowledge, and comfort. PEM physicians incorporated training into their clinical practice.
... The authors stated that the real-time video-based coaching or "hot debrief" immediately after the procedure would be difficult to implement in their clinical setting. There are well-described benefits and shortcomings of "hot" (i.e., immediate) versus "cold" (i.e., scheduled, conferencestyle) debriefs noted in the resuscitation literature (9,10). Although it may be logistically challenging to implement real-time video-based coaching, pilot work has been done in pediatric critical care (11) in a setting in which many trainees were pediatric critical care fellows. ...
... Debriefing after tasks, shifts, and events in healthcare facilitates shared reflective practice, promotes team learning, and facilitates iterative improvement adaptations in healthcare teams, as well as driving sustainable improvement and resilience of health systems ( 9 ). Clinical debriefing has been defined as "guided conversations in which members discuss, interpret and learn from recent events" ( 10 ), and has been shown to improve team processes ( 11 ), and patient outcomes (12)(13)(14), as well as financially benefit institutions ( 14 ), demonstrating its essential role in supporting the continuous development of team members, improving health systems, optimizing the quality and sustainability of care, and the potential to reduce health care inequities. Debriefing has also been shown to reduce burnout and increase staff well-being and resilience ( 15 , 16 ). ...
Background. Healthcare systems must adapt iteratively in response to external and local challenges while keeping patients and staff safe. Clinical debriefing is a cost-effective
contributor to safety culture, facilitating learning and team adaptations that lead to improved processes, patient outcomes, and staff resilience. In the aftermath of the COVID- 19 pandemic, an interest has emerged in adopting TALK© to guide clinical debriefing to promote safety, mutual support, and cultural change within healthcare teams in Latin American contexts. Aims. To evaluate the quality and applicability of TALK© debriefing training in Latin American settings and the willingness to debrief after an educational intervention. Methods. Retrospective and descriptive study, examining anonymous data collected over 18 months after completing a “TALK© Debriefing Course for Healthcare Professionals” face-to-face or online. Data collected included participant characteristics, course details, quality and applicability of the intervention, and willingness to debrief. Results. Five hundred and forty-five participants were enrolled, most from Argentina and Mexico. The overall quality of the intervention scored 19.62/20 points, obtaining 4.86/5 points for applicability. There were no significant differences between virtual and
face-to-face sessions. After the intervention, ≥93.76% of participants felt able to engage in clinical debriefing, and 97.06% reported willingness to debrief. Conclusions. Dissemination of multi-professional clinical debriefing training in Latin America is feasible and easily scalable. The quality of the educational intervention was rated excellent in both virtual and face-to-face settings, supporting the value of remote educational diffusion. Most participants in this study intervention felt prepared and willing to debrief following the intervention. © 2024 The Author(s). Published by Elsevier Inc. on behalf of Instituto Mexicano del Seguro Social (IMSS). This is an open access article under the CC BY-NC-ND license.
... [798][799][800][801][802][803] Studies assessing the impact of debriefing after cardiac arrest events demonstrate improved provider performance, 804,805 while debriefings informed by clinical data have been associated with enhanced survival outcomes from cardiac arrest. 806,807 Many different debriefing frameworks have been developed and implemented, leading to variability in how debriefing is conducted across programs and institutions. 808 Debriefing scripts and tools have been developed to help standardize the approach to debriefing during resuscitation training. ...
... 8 9 Improvements in patient outcomes with debriefing have also been noted, with studies showing increased survival rates following cardiac arrest resuscitation in paediatric intensive care units. 10 Considering the similarities between PBEs and other acute deteriorations in patient health, we explored the utility of post-PBE debriefing among staff in Child and Adolescent Mental Health Units (CAMHU) in order to reduce the rate and severity of PBEs and help promote staff well-being. ...
This manuscript presents the pioneering use of a post-event staff debriefing tool, TALK, in Acute Child and Adolescent Mental Health Units (CAMHU). While unsuccessful in reducing the rate and severity of patient behavioural events, our centre observed promising psychological benefits for CAMHU staff as a result of debriefing, with the tool promoting emotional resiliency and providing a platform for open conversations. Debriefing also served as a venue for patient concerns with care to be raised by staff, addressed and reflected in updated care plans. This initiative demonstrates the utility of debriefing to foster a culture of learning, improve staff wellness and enhance patient safety in CAMHU settings.
... Tools such as PACE can help to make this less intimidating and ensure a structured response. support the impact on clinical outcomes: one observational study of human cardiopulmonary arrest patients concluded that 52% of patients survived cardiopulmonary arrest once debriefing had been incorporated into clinical protocol, a huge improvement on the 33% before the intervention (Wolfe et al, 2014). One method of pulling focus onto communication is raised by Timothy et al (2021) in the form of a novel post-arrest debriefing tool. ...
This review draws on evidence from human medicine to assess the team factors most relevant to small animal cardiopulmonary resuscitation (CPR). It is increasingly being recognised that leadership, team building, communication and situational awareness all impact both the team's experience and clinical outcomes. Leadership training, nurse-led teams, debriefing, closed-loop communication and cognitive aids have all been shown to improve CPR performance and thus deserve consideration alongside the practical elements of arrest and resuscitation. There is limited primary evidence to support this claim in veterinary medicine. However, the mental models underpinning clinical human factors are largely seen as transferable, with veterinary governing bodies supporting their inclusion in practice culture and training.
... The debriefing script may improve the facilitator's ability to lead the debrief effectively and may enhance knowledge acquisition [33]. To elaborate, debriefings conducted after cardiac arrest resuscitations have shown associations with enhanced adherence to resuscitation protocols, increased patient survival rates, and improved neurological outcomes [47][48][49][50]. ...
Background
Currently, there are no separate debriefing models for online simulation training, and existing models simply imitate the traditional models used in on-site simulation training (the physical presence of individuals, such as students or trainees, in a simulation center). This involves hands-on, in-person training within a simulated environment to enhance practical skills and knowledge in a controlled setting. This scenario does not fully meet the requirements and capabilities of distance learning.
Objective
To develop a staged defragmented debriefing model as integrated micro-debriefing components inside an online simulation to support the development of clinical decision-making and competencies formation within medical education and offer recommendations to support the use of this debriefing model as a teaching strategy.
Methods
This descriptive study was conducted from August 2020 to September 2023. To build a staged defragmented debriefing model as integrated micro-debriefing components inside an online simulation for competencies formation the traditional debriefing model's components for on-site simulation training, simulation type, and structure, modern concepts of e-learning, and classification of the seriousness of medication errors were used. The main focus of this study was on providing a detailed account of the debriefing components for online simulation training, features, and implementation of this new teaching model. A total of 38 participants, healthcare professionals, were recruited for this study. The participants were randomly assigned to two groups: one experiencing the staged defragmented debriefing model (n = 20) and the other control group, which received traditional debriefing following simulation training (n = 18).
Results
The results allowed us to successfully develop a staged defragmented debriefing model inside the simulation that integrates micro-debriefing components located at different points of the simulation scenarios. This teaching approach was successfully implemented in online clinical case scenarios in the “ClinCaseQuest" Simulation Training Platform for continuous medical education. Additionally, an internal validation experiment comparing the effectiveness of the staged defragmented debriefing model with the traditional debriefing method demonstrated superior learning outcomes and participant satisfaction in the staged debriefing group.
Conclusions
The staged defragmented debriefing model, when integrated into online simulations, represents a promising strategy for advancing clinical decision-making skills and competencies formation in medical education. Implementation of this debriefing model as a teaching strategy holds promise for enhancing learning outcomes in medical education settings. Further research, validation, and implementation are recommended to maximize the model’s potential impact on medical education and training.
... cardiopulmonary resuscitation (CPR) quality metrics) has been associated with enhanced CPR quality 15 and patient survival outcomes from cardiac arrest. 16,17 Despite these promising findings, there is considerable variability in the way debriefings are conducted across resuscitation training programs and institutions. 18 The variability in the structure, format, and delivery of debriefings may influence the overall impact of the educational intervention. ...
Objectives
To evaluate the effectiveness of scripted debriefing relative to no use of script during debriefing in resuscitation training.
Methods
This scoping review was undertaken as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) and based on the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) extension for scoping review. MEDLINE, EMBASE, and SCOPUS were searched from inception to January 2024. We included all published studies comparing scripted debriefing vs non-scripted debriefing evaluating patient outcomes, behaviour change of learners, learning outcomes for learners and cognitive load and teaching quality for instructors.
Results
Our initial literature search identified 1238 citations. After removing 552 duplicates, reviewing the titles and abstracts of the remaining 686 articles yielded 11 for full-text review. Of these, six articles were selected for inclusion in the final analysis. The six studies described debriefing scripts varying in content, framework, scripted language and the integration of objective data. Scripted debriefing improved CPR performance, team leadership skills and knowledge acquisition, but showed no difference in teamwork performance compared to non-scripted debriefing. Scripted debriefing also improved debriefing quality and decreased cognitive load of the instructor during resuscitation training.
Conclusion
The use of a debriefing script during resuscitation education can improve CPR performance, team leader performance, knowledge acquisition and reduce the debriefer’s cognitive load. Future research should explore how debriefing scripts can be designed to optimize learning outcomes.
... 1 CD has the potential to improve outcomes for staff, teams, patients and systems. 2 3 The evidence for CD exists and continues to grow; benefits range from changes in staff attitudes 4 to favourable outcomes following cardiac arrest. 5 Despite this, some clinicians have been sceptical about the impact of CD, and there are various barriers which may limit implementation. These include lack of clear purpose, actual or perceived lack of time, lack of experienced debriefers and cultural resistance to change. ...
... It is paramount to create an emotionally or psychologically safe environment to conduct the debrief [1,5,6,20]. Facilitating a comfortable, supportive environment for learning and sharing will provide the best opportunity to optimize engagement of the involved parties. ...
Learning objectives
Review the history of debriefing and provide an Interventional Radiologist (IR) specific framework for leading an effective debrief.
Background
A debrief is often regarded as a meeting with persons who were involved in a stressful, traumatic and/or emotionally challenging situation to review processes, communicate concerns or gather feedback. The goals of these sessions can be for learning/quality improvement (QI) or psychological/emotional support, or a mix of both. Debriefing after tough situations has become a standard tool of many medical specialties, such as surgery, critical care and emergency medicine, with specialty specific literature available. However, there is a paucity of Interventional Radiology specific literature available for debriefing techniques.
Clinical findings/procedure details
We will review the history and types of debriefing and why a debrief could be considered. We will provide a framework for leading a successful debrief in Interventional Radiology.
Conclusion
Debriefing can be a useful tool for learning and QI as well as psychological or emotional support after a challenging or tough situation. Debriefing can address multiple variables and can stylistically be tailored to suit specific needs. IRs have an opportunity to take a leadership role in debriefing, providing comfort and quality improvement through communication and support.
... Clinical supervision (CS) is a way of enhancing education and training programs that emphasizes building relationships, focusing on work-related aspects and encompassing activities such as managing, supporting, developing, and evaluating the work of colleagues [1]. Supervision is frequently observed in community mental health settings and other clinical locations, such as counseling centers and hospitals [2][3][4], where a significant portion (54-75%) of practitioners receive 30-60 min of weekly supervision [5,6]. Clinical supervision is a crucial component of professional development and support in the field of health care, particularly in clinical settings [7]. ...
The purpose of this systematic review is to gather and analyze data from existing research on the effects of clinical supervision (CS) intervention on nurses’ job satisfaction and related outcomes such as stress levels, burnout, and care quality. Using the PRISMA (preferred reporting items for systematic reviews and meta-analysis) criteria, a systematic review of the research available in the databases PubMed, PsycInfo, Cochrane Library, and CINAHL, well as Google Scholar, between January 2010 and May 2023 was carried out. Out of the 760 studies assessed, only 8 met the criteria for inclusion in the review based on Hawker’s assessment tool. The results indicate that CS has a positive impact on nurses’ job satisfaction and related outcomes such as reduced burnout, stress levels, and the quality of care. The study also found that the effectiveness of CS in enhancing job satisfaction was most evident during the 6-month follow-up period. However, nurses who did not receive CS did not show any noticeable improvement in their knowledge or practice. Additionally, nurses who required more efficient clinical oversight reported little to no positive impact on their practice or training. The review also highlighted gaps in knowledge regarding the frequency and number of sessions required for the impact of CS on nurses’ job satisfaction and other outcomes. Due to the limited number of studies included in this review, further research is recommended to evaluate the influence of CS on nurses’ job satisfaction.
... The EMC promotes and tracks the completion of a "hot debrief," a focused and structured team meeting shortly after an event. [30][31][32] The debrief forms were revamped to help guide an effective team conversation, including questions about key aspects of the resuscitation, team performance and tasks critical to performing good quality CPR (See figure 2, Supplemental Digital Content 2, which shows "Hot" Debrief Form. http://links.lww.com/PQ9/A530). ...
Background
Pediatric In-hospital Cardiac Arrest (IHCA) is a rare event with a 50-55% mortality rate. Techniques of Cardiopulmonary Resuscitation (CPR), medication and electrical therapy timing, team dynamics, simulation and debriefing programs are associated with improved outcomes. This study aimed to improve outcomes after IHCA by describing and implementing quality improvement processes that cross and coordinate among traditional siloed pediatric resuscitation team structures.
Methods
We chose three outcome measures: (1) return of spontaneous circulation (ROSC), (2) 24-hour survival after IHCA, and (3) survival to hospital discharge. Process outcomes include (1) hot debriefs performed with a standardized form, (2) code documentation using a revised form, and (3) formal code team review presented to a central Emergency Management Committee, using a standardized form.
Results
One hundred and thirty-two patients experienced 176 events during the 36-month study period. Survival to hospital discharge increased from 33% during year 1 to 60% during year 2 ( P < 0.05) but decreased to 45% in year 3. Both hot debrief performance and code documentation process methods did not demonstrate widespread adoption, but formal code team review was documented in 80% of events quite rapidly.
Conclusions
There are common traits inherent to effective CPR team response. Ensuring optimal performance of these common tasks and techniques in every pediatric IHCA event in our hospital is being addressed by committee reorganization, task simplification, new technology acquisition and enhanced feedback loops. Early outcome analysis shows initial improvement in survival to hospital discharge after pediatric IHCA.
... 30 Analogous to the benefits observed in debriefing programs following high-acuity medical events, clinical debriefing after behavioral events patient should lead to improved team performance, increased awareness and problem-solving of challenges unique to the MBH population, and the prevention or reduction of the harms associated with agitated or aggressive patients having a behavioral event. [31][32][33] The aims of this study are to describe the implementation of a clinical debriefing program, the characteristics of patients who had behavioral events, the qualitative themes discussed during the debriefings, and patient and system-level outcomes associated with the program's initiation. We hypothesized that the initiation of this program would be associated with a subsequent decrease in the rate of patients requiring physical restraints for violent and self-destructive (VSD) behaviors. ...
... This step provides necessary feedback to team members and is crucial in enhancing team performance. Some studies have demonstrated that debriefing is associated with greater benefits for improving patient outcomes after cardiac arrest [50,51]. Traditional training settings may not reflect the environment of actual team-based resuscitation. ...
Background
Simulation is an increasingly used novel method for the education of medical professionals. This study aimed to systematically review the efficacy of high-fidelity (HF) simulation compared with low-fidelity (LF) simulation or no simulation in advanced life support (ALS) training.
Methods
A comprehensive search of the PubMed, Chinese Biomedicine Database, Embase, CENTRAL, ISI, and China Knowledge Resource Integrated Database was performed to identify randomized controlled trials (RCTs) that evaluated the use of HF simulation in ALS training. Quality assessment was based on the Cochrane Handbook for Systematic Reviews of Interventions version 5.0.1. The primary outcome was the improvement of knowledge and skill performance. The secondary outcomes included the participants’ confidence and satisfaction at the course conclusion, skill performance at one year, skill performance in actual resuscitation, and patient outcomes. Data were synthesized using the RevMan 5.4 software.
Results
Altogether, 25 RCTs with a total of 1,987 trainees were included in the meta-analysis. In the intervention group, 998 participants used HF manikins, whereas 989 participants received LF simulation-based or traditional training (classical training without simulation). Pooled data from the RCTs demonstrated a benefit in improvement of knowledge [standardized mean difference (SMD) = 0.38; 95% confidence interval (CI): 0.18–0.59, P = 0.0003 , I ² = 70%] and skill performance (SMD = 0.63; 95% CI: 0.21–1.04, P = 0.003, I ² = 92%) for HF simulation when compared with LF simulation and traditional training. The subgroup analysis revealed a greater benefit in knowledge with HF simulation compared with traditional training at the course conclusion (SMD = 0.51; 95% CI: 0.20–0.83, P = 0.003, I ² = 61%). Studies measuring knowledge at three months, skill performance at one year, teamwork behaviors, participants’ satisfaction and confidence demonstrated no significant benefit for HF simulation.
Conclusions
Learners using HF simulation more significantly benefited from the ALS training in terms of knowledge and skill performance at the course conclusion. However, further research is necessary to enhance long-term retention of knowledge and skill in actual resuscitation and patient’s outcomes.
... Of the survivors in the 2009-2015 Therapeutic Hypothermia for Cardiac Arrest trials, many have significant morbidity, including neurologic sequelae (4). Historically, in cohorts from the period 2008-2016, high-quality CPR was associated with improved outcomes (5)(6)(7)(8), but the quality of CPR provided was variable even in the ICU. ...
Objectives
To assess associations between outcome and cardiopulmonary resuscitation (CPR) quality for in-hospital cardiac arrest (IHCA) in children with medical cardiac, surgical cardiac, or noncardiac disease.
Design
Secondary analysis of a multicenter cluster randomized trial, the ICU-RESUScitation Project (NCT02837497, 2016–2021).
Setting
Eighteen PICUs.
Patients
Children less than or equal to 18 years old and greater than or equal to 37 weeks postconceptual age receiving chest compressions (CC) of any duration during the study.
Interventions
None
Measurements and Main Results
Of 1,100 children with IHCA, there were 273 medical cardiac (25%), 383 surgical cardiac (35%), and 444 noncardiac (40%) cases. Favorable neurologic outcome was defined as no more than moderate disability or no worsening from baseline Pediatric Cerebral Performance Category at discharge. The medical cardiac group had lower odds of survival with favorable neurologic outcomes compared with the noncardiac group (48% vs 55%; adjusted odds ratio [aOR] [95% CI], aOR 0.59 [95% CI, 0.39–0.87], p = 0.008) and surgical cardiac group (48% vs 58%; aOR 0.64 [95% CI, 0.45–0.9], p = 0.01). We failed to identify a difference in favorable outcomes between surgical cardiac and noncardiac groups. We also failed to identify differences in CC rate, CC fraction, ventilation rate, intra-arrest average target diastolic or systolic blood pressure between medical cardiac versus noncardiac, and surgical cardiac versus noncardiac groups. The surgical cardiac group had lower odds of achieving target CC depth compared to the noncardiac group (OR 0.15 [95% CI, 0.02–0.52], p = 0.001). We failed to identify a difference in the percentage of patients achieving target CC depth when comparing medical cardiac versus noncardiac groups.
Conclusions
In pediatric IHCA, medical cardiac patients had lower odds of survival with favorable neurologic outcomes compared with noncardiac and surgical cardiac patients. We failed to find differences in CPR quality between medical cardiac and noncardiac patients, but there were lower odds of achieving target CC depth in surgical cardiac compared to noncardiac patients.
... [13][14][15] Singlecentre data suggest that an educational bundle including point-ofcare bedside CPR training on manikins, and structured post-arrest debriefings are associated with improved neurologic outcome in children. 16 The multicentre Improving Outcomes from Paediatric Cardiac Arrest (ICU-RESUS) study assessed whether an educational bundle of structured debriefings that emphasized physiologic resuscitation targets, and point-of-care bedside education (simulated CPR with real-time feedback on a manikin) improved the rate of survival to hospital discharge with favourable neurologic outcome after p-IHCA. 17 Compared with usual care, the bundled intervention did not significantly improve survival to hospital discharge with favourable neurologic outcome in that study. ...
Aim:
To evaluate associations between characteristics of simulated point-of-care cardiopulmonary resuscitation (CPR) training with simulated and actual intensive care unit (ICU) CPR performance, and with outcomes of children after in-hospital cardiac arrest.
Methods:
This is a pre-specified secondary analysis of the ICU-RESUScitation Project; a prospective, multicentre cluster randomized interventional trial conducted in 18 ICUs from October 2016-March 2021. Point-of-care bedside simulations with real-time feedback to allow multidisciplinary ICU staff to practice CPR on a portable manikin were performed and quality metrics (rate, depth, release velocity, chest compression fraction) were recorded. Actual CPR performance was recorded for children 37 weeks post-conceptual age to 18 years who received chest compressions of any duration, and included intra-arrest haemodynamics and CPR mechanics. Outcomes included survival to hospital discharge with favourable neurologic status.
Results:
Overall, 18,912 point-of-care simulations were included. Simulation characteristics associated with both simulation and actual performance included site, participant discipline, and timing of simulation training. Simulation characteristics were not associated with survival with favourable neurologic outcome. However, participants in the top 3 sites for improvement in survival with favourable neurologic outcome were more likely to have participated in a simulation in the past month, on a weekday day, to be nurses, and to achieve targeted depth of compression and chest compression fraction goals during simulations than the bottom 3 sites.
Conclusions:
Point-of-care simulation characteristics were associated with both simulated and actual CPR performance. More recent simulation, increased nursing participation, and simulation training during daytime hours may improve CPR performance.
... 7,8 POHCA patients require rapid interventions early on including high-quality CPR, airway control, early epinephrine, and rapid defibrillation, as needed. 7,[9][10][11][12][13] Emphasis is also placed on post cardiac arrest care (PCAC), specifically, targeted temperature management (TTM), oxygen (O2) and carbon dioxide (CO2) targeting, hemodynamic monitoring, and prognostication, among other factors. 8 However, the in-hospital management of ongoing arrest in POHCA patients has not been investigated. ...
Introduction:
Pediatric out of hospital cardiac arrest (POHCA) is rare, with high mortality and neurological morbidity. Adherence to Pediatric Advanced Life Support guidelines standardizes in-hospital care and improves outcomes. We hypothesized that in-hospital care of POHCA patients was variable and deviations from guidelines were associated with higher mortality.
Methods:
POHCA patients in the London-Middlesex region between January 2012 and June 2020 were included. The care of children with ongoing arrest (intra-arrest) and post-arrest outcomes were reviewed using the Children's Hospital, London Health Sciences Centre (LHSC) patient database and the Adverse Event Management System.
Results:
50 POHCA patients arrived to hospital, with 15 (30%) patients admitted and 2 (4.0%) surviving to discharge, both with poor neurological outcomes and no improvement at 90 days. Deviations occurred at every event with intra-arrest care deviations occurring mostly in medication delivery and defibrillation (98%). Post-arrest deviations occurred mostly in temperature monitoring (60%). Data missingness was 15.9% in the intra-arrest and 1.7% in the post-arrest group.
Discussion:
Deviations commonly occurred in both in-hospital arrest and post-arrest care. The study was under-powered to identify associations between DEVs and outcomes. Future work includes addressing specific deviations in intra-arrest and post-arrest care of POHCA patients and standardizing electronic documentation.
... However, if disruptive events are here to stay (case in point, the pandemic) and if the current conditions of the system are not ideal for fully embracing plasticity, then maybe this is the time to start pondering about creative ways in which we can strategically infuse plasticity in our healthcare teams to leverage their capacity for resilient teaming. For instance, many have demonstrated the benefits of debriefing in team training, including improved clinical outcomes, team performance and identification of errors [34][35][36]. While debriefing could be a powerful strategy for infusing plasticity, evidence shows that it is still an underused team training strategy [37]. ...
The resilience of a healthcare system hinges on the adaptability of its teams. Thus far, healthcare teams have relied on well-defined scopes of practice to fulfill their safety mandate. While this feature has proven effective when dealing with stable situations, when it comes to disruptive events, healthcare teams find themselves navigating a fine balance between safety and resilience. Therefore, a better understanding of how the safety vs resilience trade-off varies under different circumstances is necessary if we are to promote and better train for resilience in modern healthcare teams. In this paper, we aim to bring awareness to the sociobiology analogy that healthcare teams might find useful during moments when safety and adaptability have the potential to conflict. Three principles underpin the sociobiology analogy: communication, decentralization, and plasticity. Of particular interest in this paper is plasticity whereby swapping roles or tasks becomes an adaptive, rather than a maladaptive, response teams could embrace when facing disruptive situations. While plasticity has naturally evolved in social insects, infusing plasticity in healthcare teams requires intentional training. Inspired by the sociobiology analogy, such training must value the ability: a) to read each other's cues and miscues, b) to step aside when others had the necessary skills, even if outside their scope, c) to deviate from protocols, and d) to foster cross-training. If the goal is to increase a team's behavioural flexibility and boost their resilience, this training mindset should become second nature.
... [23] In this context, Cutrer and colleagues described informed self-assessment as important with feedback that is 'clear, timely, specific and constructive feedback offered by trusted, credible supervisors' . These ideas would appear relevant to debriefer development with the DART tool, as well as other assessment tools aiding this process • No correlation/association was observed between DART scores and DASH scores • In other settings, simple objective data has been clearly shown to improve actual performance as follows: 1) Real-time objective audio-visual feedback of CPR performance such as chest compression depth, chest compression rate, and ventilation rate lead to improvements of those objective measures of CPR performance and improvements in the rate of ROSC [2,23] 2) Real-time quantitative feedback in the form of mean concentric velocity displayed in front of participants leads to improvements in physical performance of strength exercises and improvements in motivation, competitiveness, and mood [24] Cutrer et al. suggested that using data can be a powerful tool to change behaviour [25] Implication What is the impact of the DART tool on debriefers? ...
Background:
Debriefing is crucial for enhancing learning following healthcare simulation. Various validated tools have been shown to have contextual value for assessing debriefers. The Debriefing Assessment in Real Time (DART) tool may offer an alternative or additional assessment of conversational dynamics during debriefings.
Methods:
This is a multi-method international study investigating reliability and validity. Enrolled raters (n = 12) were active simulation educators. Following tool training, the raters were asked to score a mixed sample of debriefings. Descriptive statistics are recorded, with coefficient of variation (CV%) and Cronbach's α used to estimate reliability. Raters returned a detailed reflective survey following their contribution. Kane's framework was used to construct validity arguments.
Results:
The 8 debriefings (μ = 15.4 min (SD 2.7)) included 45 interdisciplinary learners at various levels of training. Reliability (mean CV%) for key components was as follows: instructor questions μ = 14.7%, instructor statements μ = 34.1%, and trainee responses μ = 29.0%. Cronbach α ranged from 0.852 to 0.978 across the debriefings. Post-experience responses suggested that DARTs can highlight suboptimal practices including unqualified lecturing by debriefers.
Conclusion:
The DART demonstrated acceptable reliability and may have a limited role in assessment of healthcare simulation debriefing. Inherent complexity and emergent properties of debriefing practice should be accounted for when using this tool.
Objective
The epidemiology of pediatric cardiac arrest in Europe is largely unknown. We aimed to characterize pediatric cardiac arrest registries and obtain the first survival outcome data on pediatric cardiac arrest in Europe.
Design
This is a prospective multinational survey.
Setting
We surveyed all 53 countries in Europe asking about: the existence registries for pediatric out-of-hospital cardiac arrest (pOHCA) and/or in-hospital cardiac arrest (pIHCA)), the data collected, and the structure of the registries. Subsequently, we investigated outcomes (number of pOHCA/pIHCA since start of the registry, return of spontaneous circulation (ROSC), survival to hospital discharge/30-day survival) from the countries with active registries.
Patients and interventions
We obtained information from 33 countries including 25 of the 27 European Union states.
Measurements and main results
Thirteen countries (39%) have an ongoing pediatric cardiac arrest registry (pOHCA: 11 countries, pIHCA: 8 countries). All use the Utstein template for data collection. Five countries (15%) collect data about CPR quality. Eleven countries (33%) expressed interest in European collaboration on registry data. Overall, 13 countries reported data on outcomes from a total of 17,708 pOHCAs and 2,743 pIHCAs. The ROSC rate after pOHCA ranges from 10% to 72% as compared to 60% to 72% after pIHCA. Survival to hospital discharge ranges from 16% to 39% after pOHCA as compared to 32% to 57% after pIHCA.
Conclusions
Less than 40% of the European countries have a pOHCA and/or pIHCA registry, reporting a wide variety in survival rates, especially after pOHCA. More systematic data collection is needed to identify the real incidence and outcomes from pediatric cardiac arrest, ideally through a joint European registry.
Background
The quality cardiopulmonary resuscitation (CPR) coach role was developed for hospital-based resuscitation teams. This supplementary team member (CPR coach) provides real-time, verbal feedback on chest compression quality to compressors during a cardiac arrest.
Objectives
To evaluate the impact of a quality CPR coach training intervention on resuscitation teams, including presence of coaches on teams and physiologic metrics of quality CPR delivery in real compression events.
Methods
The quality CPR coach curriculum and role implementation were designed and evaluated using a logic model framework. Medical records of patients who had in-unit cardiopulmonary arrests were reviewed retrospectively. Data included physiologic metrics of quality CPR delivery. Analysis included descriptive statistics and comparison of arrest data before and after the intervention.
Results
A total of 79 cardiopulmonary arrests were analyzed: 40 before and 39 after the intervention. Presence of a quality CPR coach on resuscitation teams was more frequent after training, increasing from 35% before the intervention to 72% after (P = .002). No significant difference was found in the frequency of application of Zoll defibrillator pads. Metrics of quality CPR delivery and adherence with American Heart Association recommendations were either unchanged or improved after the intervention.
Conclusions
The quality CPR coach training intervention significantly increased coach presence on code teams, which was associated with clinically significant improvements in some metrics of quality CPR delivery in real cardiopulmonary arrests.
Background
A critical incident is described as any unplanned event which causes, or has the potential to cause, injury to a patient. Critical incident debriefing is a team discussion to gather facts and analyse the experience, evaluate lessons learned and provide staff with support. However, this phase is often neglected.
Methods
This UK-based explorative qualitative study aims to explore perioperative practitioners’ experiences of critical incident debriefing. Data were collected from six participants through audio-recorded, semi-structured interviews. Data were analysed using a thematic analysis framework.
Results
Five themes emerged detailing the advantages of critical incident debriefing, including addressing staff’s personal needs and learning lessons from incidents, and the disadvantages such as time constraints and unsupportive/uninformative debriefs leading to poor-quality debriefs.
Conclusions
Implementation of a short debrief immediately post-incident to address immediate concerns, a later in-depth debrief and additional training for facilitators were recommended to improve debrief quality.
This perspective focuses on the role of healthcare simulation in training and implementing processes aimed at improving the quality of care and patient safety. Evidence of the effectiveness of simulation in improving clinical performance, reducing healthcare costs and raising professional education standards is presented. In light of this evidence, we propose to consider simulation-based education as an integrative training modality in the preparation of health professionals in the field of Public Health. A pilot project is presented with the aim of training professionals capable of further contributing to improving the quality and safety of patients through an interdisciplinary and innovative approach.
BACKGROUND AND OBJECTIVES
Debriefings are an underutilized opportunity to enhance team performance and safety culture. Little is known about the impact of postclinical event debriefing programs in Pediatric Hospital Medicine (PHM). We sought to develop a standardized debriefing process with multidisciplinary involvement after all clinical events on PHM service lines. Our primary aim was to achieve 75% debriefing completion rate over 12 months with debriefing duration less than 10 minutes.
METHODS
A standardized postclinical event debriefing process was created at a large tertiary children’s hospital. We aimed to debrief after clinical events on PHM services. The debriefing process was developed with key stakeholders and used a key driver diagram and Plan-Do-Study-Act cycles to refine the process. The project team reviewed the data monthly.
RESULTS
During our 20-month study period, debriefing completion rate sustained a median of 66% with a median debriefing time of 7 minutes. Most debriefings (61%) had all core team members present with attending physicians (pediatric hospitalists) being absent most often. Barriers to debriefing with all core members present included service type, time of day, and shift change. Process changes were implemented based on concerns addressed in the debriefings.
CONCLUSIONS
Multidisciplinary, postclinical event debriefings were successfully implemented on inpatient pediatric wards. Future steps include process implementation on non-PHM units in our hospital based on expressed interest and to further assess how debriefings optimize team performance and improve clinical outcomes.
Introduction
Clinical debriefing (CD) improves teamwork and patient care. It is implemented across a range of clinical contexts, but delivery and structure are variable. Furthermore, terminology to describe CD is also inconsistent and often ambiguous. This variability and the lack of clear terminology obstructs understanding and normalisation in practice. This review seeks to examine the contextual factors relating to different CD approaches with the aim to differentiate them to align with the needs of different clinical contexts.
Methods
Articles describing CD were extracted from Medline, CINAHL, ERIC, PubMed, PsychINFO and Academic Search Complete. Empirical studies describing CD that involved two or more professions were eligible for inclusion. Included papers were charted and analysed using the Who-What-When-Where-Why-How model to examine contextual factors which were then used to develop categories of CD. Factors relating to what prompted debriefing and when debriefing occurred were used to differentiate CD approaches.
Results
Forty-six papers were identified. CD was identified as either prompted or routine, and within these overarching categories debriefing was further differentiated by the timing of the debrief. Prompted CD was either immediate or delayed and routine CD was postoperative or end of shift. Some contextual factors were unique to each category while others were relatively heterogeneous. These categories help clarify the alignment between the context and the intention of CD.
Conclusions
The proposed categories offer a practical way to examine and discuss CD which may inform decisions about implementation. By differentiating CD according to relevant contextual factors, these categories may reduce confusion which currently hinders discourse and implementation. The findings from this review promote context-specific language and a shift away from conceptions of CD that embody a one-size-fits-all approach.
Aim:
Develop a novel, physiology-based measurement of duty cycle (Arterial BloodPressure - Area Duty Cycle [ABP-ADC]) and evaluate the association of ABP-ADCwith intra-arrest hemodynamics and patient outcomes.
Methods:
This was a secondary retrospective study of prospectively collected datafrom the ICU-RESUS trial (NCT02837497). Invasive arterial waveform data were usedto derive ABP-ADC. The primary exposure was ABP-ADC group (<30%; 30-35%;>35%). The primary outcome was systolic blood pressure (sBP). Secondary outcomesincluded intra-arrest physiologic goals, CPR quality targets, and patient outcomes. Inan exploratory analysis, adjusted splines and receiver operating characteristic (ROC)curves were used to determine an optimal ABP-ADC associated with improvedhemodynamics and outcomes using a multivariable model.
Results:
Of 1129 CPR events, 273 had evaluable arterial waveform data. Mean agewas 2.9 + 4.9 years. Mean ABP-ADC was 32.5% + 5.0%. In univariable analysis,higher ABP-ADC was associated with lower sBP (p<0.01) and failing to achieve sBPtargets (p<0.01). Other intra-arrest physiologic parameters, quality metrics, and patientoutcomes were similar across ABP-ADC groups. Using spline / ROC analysis andclinical judgement, the optimal ABP-ADC cut point was set at 33%. On multivariableanalysis, sBP was significantly higher (point estimate 13.18 mmHg, CI95 5.30 - 21.07,p<0.01) among patients with ABP-ADC <33%. Other intra-arrest physiologic andpatient outcomes were similar.
Conclusions:
In this multicenter cohort, a lower ABP-ADC was associated with highersBPs during CPR. Although ABP-ADC was not associated with outcomes, furtherstudies are needed to define the interactions between CPR mechanics and intra-arrestpatient physiology.
This chapter explores the means by which practicing intensivists address poor outcomes after they have occurred. That is, advice around managing the aftermath of adverse events, mistakes, and deaths. Key to this process is the need to balance the clinical need for a close examination of the events with the potential emotional distress such processes can induce among those that were present. The risk management process is discussed as well as the importance of an open, honest approach when speaking with affected family members. The chapter concludes with a review of debriefing approaches and the value of professional mental health support for those involved in such events.KeywordsRiskHarmErrorResilienceCopingDebriefingRoot cause analysis
Objective:
Hot debriefings are communications among team members occurring shortly after an event. They have been shown to improve team performance and communication. Best practice guidelines encourage hot debriefings, but these are often not routinely performed. We aim to describe the development and implementation of a multidisciplinary hot debriefing process in our pediatric emergency department (ED), and its impact on hot debriefing completion and provider perceptions.
Methods:
An internal tool and protocol for hot debriefings were developed by integrating responses from a survey of those who work in the ED at our institution and previously published debriefing tools. Charge nurses and pediatric emergency medicine physicians were trained to lead hot debriefings. Surveys on the perception of hot debriefings were administered before and 6 months postimplementation.Twelve-month baseline data were established by asking physicians who cared for patients who died in the ED or within 48 hours of admission to recall debrief completion. Debriefs were then prospectively tracked for 6 months postimplementation.
Results:
Debrief completion for patient deaths in the ED or within 48 hours of admission increased from 23% (5/22) to 75% (12/16) (P < 0.001). When assessing just those deaths within the ED, this number increased from 31% (5/16) to 85% (11/13) (P < 0.001).There were 98 responses to a baseline survey (response rate, 60.5%). Most who were surveyed felt that debriefs rarely occurred, preferred hot debriefings to cold debriefings, and felt that more hot debriefings should occur. Perceived barriers included lack of time, interest, protocol, trained facilitators, departmental support, and inability to gather the team.There were 88 responses to a postintervention survey (response rate, 56.8%), 50 of which had participated in a debrief and were included in analysis. Those surveyed felt that debriefs occurred more often and were more often valuable. Most perceived that barriers were significantly reduced. Most respondents felt that hot debriefs helped address systems issues and improved performance.
Conclusions:
Implementation of a protocol for physician or charge nurse-led hot debriefings in our pediatric ED resulted in increased completion, perceived barrier reduction, and a uniform approach to address identified issues. Pediatric EDs should consider adoption of a hot debriefing protocol given these benefits.
In-hospital cardiac arrests that occur outside of the intensive care unit may require transportation during active cardiopulmonary resuscitation. Studies have shown that high-quality cardiopulmonary resuscitation is imperative for survival with preserved neurologic function. We sought to determine if high-quality cardiopulmonary resuscitation is maintained during simulated transportation of paediatric in-hospital cardiac arrest.
Randomized crossover simulated study of paediatric in-hospital cardiac arrest with 10 teams composed of five providers (physicians, advanced practice providers, nurses and respiratory therapists). Teams remained in a simulation room or transported the mannequin between two rooms. The primary analysis compared chest compression fraction in stationary versus transport simulations. Secondary analyses included additional cardiopulmonary resuscitation quality metrics with comparison to the 2015 American Heart Association standards.
There was no significant difference in chest compression fraction or rate between the transport and stationary groups. 92%, 72% and 26% of epochs met American Heart Association criteria for compression fraction, rate and depth, respectively. Stationary simulations were more likely to meet recommendations for combined quality metrics, including compression fraction and rate (77 vs. 53;
Chest compression fraction was preserved during simulated in-hospital cardiac arrest with transport. However, the transport simulation was less likely to meet American Heart Association recommendations for combined metrics. Similar to previous cardiopulmonary resuscitation quality studies, both teams failed to meet depth requirements in the majority of simulations.
Background
Simulation is an increasingly used novel method for the education of medical professionals.This study aimed to systematically review the efficacy of high-fidelity (HF) simulation compared with low-fidelity (LF) simulation or no simulation in advanced life support (ALS) training.
Methods
A comprehensive search of the PubMed, Chinese Biomedicine Database, Embase, CENTRAL, ISI, and China Knowledge Resource Integrated Database was performed to identify randomized controlled trials (RCTs) that evaluated the use of HF simulation in ACLS training. Quality assessment was based on the Cochrane Handbook for Systematic Reviews of Interventions version 5.0.1. The primary outcome was the improvement of knowledge and skill performance. The secondary outcomes included the participants’ confidence and satisfaction at the course conclusion, skill performance at one year, skill performance in actual resuscitation, and patient outcomes. Data were synthesized using the RevMan 5.4 software.
Results
Altogether, 25 RCTs with a total of 1987 trainees were included in the meta-analysis. In the intervention group, 998 participants used HF manikins, whereas 989 participants received LF simulation-based or traditional training (classical training without simulation). Pooled data from the RCTs demonstrated a benefit in improvement of knowledge [standardized mean difference (SMD) = 0.38; 95% confidence interval (CI): 0.18–0.59, P = 0.0003, I² = 71%] and skill performance (SMD = 0.63; 95% CI: 0.21–1.04, P = 0.003, I² = 93%) for HF simulation when compared with LF simulation and traditional training. The subgroup analysis revealed a greater benefit in knowledge with HF simulation compared with traditional training at the course conclusion (SMD = 0.50; 95% CI: 0.17–0.83, P = 0.003, I² = 67%). Studies measuring knowledge at three months, skill performance at one year, teamwork behaviors, participants’ satisfaction and confidence demonstrated no significant benefit for HF simulation.
Conclusions
Learners using HF simulation more significantly benefited from the ALS training in terms of knowledge and skill performance at the course conclusion. However, further research is necessary to enhance long-term retention of knowledge and skill in actual resuscitation and patient’s outcomes.
Resuscitations are complex events that require teamwork to succeed. In addition to the technical skills involved, a host of nontechnical skills are critical for optimal medical care delivery. These skills include mental preparation; planning for tasks and roles; leadership to guide resuscitation progress; and clear, closed-loop communication. Concerns and error detection should be escalated in an established format. Debriefing after the event helps identify learning points to carry forward for the next resuscitation. Support of the team providing this intense form of care is crucial to protect the mental health and function of providers.
Background and objectives
Clinical debriefing (CD) following a clinical event has been found to confer benefits for staff and has potential to improve patient outcomes. Use of a structured tool to facilitate CD may provide a more standardised approach and help overcome barriers to CD; however, we presently know little about the tools available. This systematic review aimed to identify tools for CD in order to explore their attributes and evidence for use.
Methods
A systematic review was conducted in line with PRISMA standards. Five databases were searched. Data were extracted using an electronic form and analysed using critical qualitative synthesis. This was guided by two frameworks: the ‘5 Es’ (defining attributes of CD: educated/experienced facilitator, environment, education, evaluation and emotions) and the modified Kirkpatrick’s levels. Tool utility was determined by a scoring system based on these frameworks.
Results
Twenty-one studies were included in the systematic review. All the tools were designed for use in an acute care setting. Criteria for debriefing were related to major or adverse clinical events or on staff request. Most tools contained guidance on facilitator role, physical environment and made suggestions relating to psychological safety. All tools addressed points for education and evaluation, although few described a process for implementing change. Staff emotions were variably addressed. Many tools reported evidence for use; however, this was generally low-level, with only one tool demonstrating improved patient outcomes.
Conclusion
Recommendations for practice based on the findings are made. Future research should aim to further examine outcomes evidence of these tools in order to optimise the potential of CD tools for individuals, teams, healthcare systems and patients.
Background:
Despite advances in resuscitation care in recent years, it is not clear whether survival and neurologic function after in-hospital cardiac arrest have improved over time.
Methods:
We identified all adults who had an in-hospital cardiac arrest at 374 hospitals in the Get with the Guidelines-Resuscitation registry between 2000 and 2009. Using multivariable regression, we examined temporal trends in risk-adjusted rates of survival to discharge. Additional analyses explored whether trends were due to improved survival during acute resuscitation or postresuscitation care and whether they occurred at the expense of greater neurologic disability in survivors.
Results:
Among 84,625 hospitalized patients with cardiac arrest, 79.3% had an initial rhythm of asystole or pulseless electrical activity, and 20.7% had ventricular fibrillation or pulseless ventricular tachycardia. The proportion of cardiac arrests due to asystole or pulseless electrical activity increased over time (P<0.001 for trend). Risk-adjusted rates of survival to discharge increased from 13.7% in 2000 to 22.3% in 2009 (adjusted rate ratio per year, 1.04; 95% confidence interval [CI], 1.03 to 1.06; P<0.001 for trend). Survival improvement was similar in the two rhythm groups and was due to improvement in both acute resuscitation survival and postresuscitation survival. Rates of clinically significant neurologic disability among survivors decreased over time, with a risk-adjusted rate of 32.9% in 2000 and 28.1% in 2009 (adjusted rate ratio per year, 0.98; 95% CI, 0.97 to 1.00; P=0.02 for trend).
Conclusions:
Both survival and neurologic outcomes after in-hospital cardiac arrest have improved during the past decade at hospitals participating in a large national quality-improvement registry. (Funded by the American Heart Association.).
To investigate the effectiveness of brief bedside cardiopulmonary resuscitation (CPR) training to improve the skill retention of hospital-based pediatric providers. We hypothesized that a low-dose, high-frequency training program (booster training) would improve CPR skill retention.
CPR recording/feedback defibrillators were used to evaluate CPR quality during simulated arrest. Basic life support-certified, hospital-based providers were randomly assigned to 1 of 4 study arms: (1) instructor-only training; (2) automated defibrillator feedback only; (3) instructor training combined with automated feedback; and (4) control (no structured training). Each session (time: 0, 1, 3, and 6 months after training) consisted of a pretraining evaluation (60 seconds), booster training (120 seconds), and a posttraining evaluation (60 seconds). Excellent CPR was defined as chest compression (CC) depth ≥ one-third anterior-posterior chest depth, rate ≥90 and ≤120 CC per minute, ≤20% of CCs with incomplete release (>2500 g), and no flow fraction ≤ 0.30.
Eighty-nine providers were randomly assigned; 74 (83%) completed all sessions. Retention of CPR skills was 2.3 times (95% confidence interval [CI]: 1.1-4.5; P=.02) more likely after 2 trainings and 2.9 times (95% CI: 1.4-6.2; P=.005) more likely after 3 trainings. The automated defibrillator feedback only group had lower retention rates compared with the instructor-only training group (odds ratio: 0.41 [95% CI: 0.17-0.97]; P = .043).
Brief bedside booster CPR training improves CPR skill retention. Our data reveal that instructor-led training improves retention compared with automated feedback training alone. Future studies should investigate whether bedside training improves CPR quality during actual pediatric arrests.
To investigate whether real-time audio and visual feedback during cardiopulmonary resuscitation outside hospital increases the proportion of subjects who achieved prehospital return of spontaneous circulation.
A cluster-randomised trial.
1586 people having cardiac arrest outside hospital in whom resuscitation was attempted by emergency medical services (771 procedures without feedback, 815 with feedback).
Emergency medical services from three sites within the Resuscitation Outcomes Consortium in the United States and Canada.
Real-time audio and visual feedback on cardiopulmonary resuscitation (CPR) provided by the monitor-defibrillator.
Prehospital return of spontaneous circulation after CPR.
Baseline patient and emergency medical service characteristics did not differ between groups. Emergency medical services muted the audible feedback in 14% of cases during the period with feedback. Compared with CPR clusters lacking feedback, clusters assigned to feedback were associated with increased proportion of time in which chest compressions were provided (64% v 66%, cluster-adjusted difference 1.9 (95% CI 0.4 to 3.4)), increased compression depth (38 v 40 mm, adjusted difference 1.6 (0.5 to 2.7)), and decreased proportion of compressions with incomplete release (15% v 10%, adjusted difference -3.4 (-5.2 to -1.5)). However, frequency of prehospital return of spontaneous circulation did not differ according to feedback status (45% v 44%, adjusted difference 0.1% (-4.4% to 4.6%)), nor did the presence of a pulse at hospital arrival (32% v 32%, adjusted difference -0.8 (-4.9 to 3.4)), survival to discharge (12% v 11%, adjusted difference -1.5 (-3.9 to 0.9)), or awake at hospital discharge (10% v 10%, adjusted difference -0.2 (-2.5 to 2.1)).
Real-time visual and audible feedback during CPR altered performance to more closely conform with guidelines. However, these changes in CPR performance were not associated with improvements in return of spontaneous circulation or other clinical outcomes. Trial Registration Clinical Trials NCT00539539.
The following guidelines are an interpretation of the evidence presented in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 1 ). They apply primarily to newly born infants undergoing transition from intrauterine to extrauterine life, but the recommendations are also applicable to neonates who have completed perinatal transition and require resuscitation during the first few weeks to months following birth. Practitioners who resuscitate infants at birth or at any time during the initial hospital admission should consider following these guidelines. For the purposes of these guidelines, the terms newborn and neonate are intended to apply to any infant during the initial hospitalization. The term newly born is intended to apply specifically to an infant at the time of birth. Approximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitative measures. 2,3 Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large total number of births, a sizable number will require some degree of resuscitation. Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following 3 characteristics: ● Term gestation? ● Crying or breathing? ● Good muscle tone? If the answer to all 3 of these questions is “yes,” the baby does not need resuscitation and should not be separated from the mother. The baby should be dried, placed skin-to-skin with the mother, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing. If the answer to any of these assessment questions is “no,” the infant should receive one or more of the following 4 categories of action in sequence:
Few data exist on pediatric cardiopulmonary resuscitation (CPR) quality. This study is the first to evaluate actual in-hospital pediatric CPR. We hypothesized that with bedside CPR training and corrective feedback, CPR quality can approach American Heart Association (AHA) targets.
Using CPR recording/feedback defibrillators, quality of CPR was assessed for patients >or=8 years of age who suffered a cardiac arrest in the PICU or emergency department (ED). Before and during the study, a bedside CPR training program was initiated.
Between October 2006 and February 2008, twenty events in 18 patients met inclusion criteria and resulted in 36749 evaluable chest compressions (CCs) during 392.3 minutes of arrest. CCs were shallow (<38 mm or <1.5 in) in 27.2% (9998 of 36749), with excessive residual leaning force (>or=2500 g) in 23.4% (8611 of 36749). Segmental analysis of the first 5 minutes of the events demonstrated that shallow CCs and excessive residual leaning force were less prevalent during the first 5 minutes. AHA targets were not achieved for CC rate in 62 (43.1%) of 144 segments, CC depth in 52 (36.1%) of 144 segments, and residual leaning force in 53 (36.8%) of 144 segments.
This prospective, observational study demonstrates feasibility of monitoring in-hospital pediatric CPR. Even with bedside CPR retraining and corrective audiovisual feedback, CPR quality frequently did not meet AHA targets. Importantly, no flow fraction target of 10% was achieved. Future studies should investigate novel educational methods and targeted feedback technologies.
The health and policy implications of regional variation in incidence and outcome of out-of-hospital cardiac arrest remain to be determined.
To evaluate whether cardiac arrest incidence and outcome differ across geographic regions.
Prospective observational study (the Resuscitation Outcomes Consortium) of all out-of-hospital cardiac arrests in 10 North American sites (8 US and 2 Canadian) from May 1, 2006, to April 30, 2007, followed up to hospital discharge, and including data available as of June 28, 2008. Cases (aged 0-108 years) were assessed by organized emergency medical services (EMS) personnel, did not have traumatic injury, and received attempts at external defibrillation or chest compressions or resuscitation was not attempted. Census data were used to determine rates adjusted for age and sex.
Incidence rate, mortality rate, case-fatality rate, and survival to discharge for patients assessed or treated by EMS personnel or with an initial rhythm of ventricular fibrillation.
Among the 10 sites, the total catchment population was 21.4 million, and there were 20,520 cardiac arrests. A total of 11,898 (58.0%) had resuscitation attempted; 2729 (22.9% of treated) had initial rhythm of ventricular fibrillation or ventricular tachycardia or rhythms that were shockable by an automated external defibrillator; and 954 (4.6% of total) were discharged alive. The median incidence of EMS-treated cardiac arrest across sites was 52.1 (interquartile range [IQR], 48.0-70.1) per 100,000 population; survival ranged from 3.0% to 16.3%, with a median of 8.4% (IQR, 5.4%-10.4%). Median ventricular fibrillation incidence was 12.6 (IQR, 10.6-5.2) per 100,000 population; survival ranged from 7.7% to 39.9%, with a median of 22.0% (IQR, 15.0%-24.4%), with significant differences across sites for incidence and survival (P<.001).
In this study involving 10 geographic regions in North America, there were significant and important regional differences in out-of-hospital cardiac arrest incidence and outcome.
The survival benefit of well-performed cardiopulmonary resuscitation (CPR) is well-documented, but little objective data exist regarding actual CPR quality during cardiac arrest. Recent studies have challenged the notion that CPR is uniformly performed according to established international guidelines.
To measure multiple parameters of in-hospital CPR quality and to determine compliance with published American Heart Association and international guidelines.
A prospective observational study of 67 patients who experienced in-hospital cardiac arrest at the University of Chicago Hospitals, Chicago, Ill, between December 11, 2002, and April 5, 2004. Using a monitor/defibrillator with novel additional sensing capabilities, the parameters of CPR quality including chest compression rate, compression depth, ventilation rate, and the fraction of arrest time without chest compressions (no-flow fraction) were recorded.
Adherence to American Heart Association and international CPR guidelines.
Analysis of the first 5 minutes of each resuscitation by 30-second segments revealed that chest compression rates were less than 90/min in 28.1% of segments. Compression depth was too shallow (defined as <38 mm) for 37.4% of compressions. Ventilation rates were high, with 60.9% of segments containing a rate of more than 20/min. Additionally, the mean (SD) no-flow fraction was 0.24 (0.18). A 10-second pause each minute of arrest would yield a no-flow fraction of 0.17. A total of 27 patients (40.3%) achieved return of spontaneous circulation and 7 (10.4%) were discharged from the hospital.
In this study of in-hospital cardiac arrest, the quality of multiple parameters of CPR was inconsistent and often did not meet published guideline recommendations, even when performed by well-trained hospital staff. The importance of high-quality CPR suggests the need for rescuer feedback and monitoring of CPR quality during resuscitation efforts.
Cardiac arrests in adults are often due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), which are associated with better outcomes than asystole or pulseless electrical activity (PEA). Cardiac arrests in children are typically asystole or PEA.
To test the hypothesis that children have relatively fewer in-hospital cardiac arrests associated with VF or pulseless VT compared with adults and, therefore, worse survival outcomes.
A prospective observational study from a multicenter registry (National Registry of Cardiopulmonary Resuscitation) of cardiac arrests in 253 US and Canadian hospitals between January 1, 2000, and March 30, 2004. A total of 36,902 adults (> or =18 years) and 880 children (<18 years) with pulseless cardiac arrests requiring chest compressions, defibrillation, or both were assessed. Cardiac arrests occurring in the delivery department, neonatal intensive care unit, and in the out-of-hospital setting were excluded.
Survival to hospital discharge.
The rate of survival to hospital discharge following pulseless cardiac arrest was higher in children than adults (27% [236/880] vs 18% [6485/36,902]; adjusted odds ratio [OR], 2.29; 95% confidence interval [CI], 1.95-2.68). Of these survivors, 65% (154/236) of children and 73% (4737/6485) of adults had good neurological outcome. The prevalence of VF or pulseless VT as the first documented pulseless rhythm was 14% (120/880) in children and 23% (8361/36,902) in adults (OR, 0.54; 95% CI, 0.44-0.65; P<.001). The prevalence of asystole was 40% (350) in children and 35% (13 024) in adults (OR, 1.20; 95% CI, 1.10-1.40; P = .006), whereas the prevalence of PEA was 24% (213) in children and 32% (11,963) in adults (OR, 0.67; 95% CI, 0.57-0.78; P<.001). After adjustment for differences in preexisting conditions, interventions in place at time of arrest, witnessed and/or monitored status, time to defibrillation of VF or pulseless VT, intensive care unit location of arrest, and duration of cardiopulmonary resuscitation, only first documented pulseless arrest rhythm remained significantly associated with differential survival to discharge (24% [135/563] in children vs 11% [2719/24,987] in adults with asystole and PEA; adjusted OR, 2.73; 95% CI, 2.23-3.32).
In this multicenter registry of in-hospital cardiac arrest, the first documented pulseless arrest rhythm was typically asystole or PEA in both children and adults. Because of better survival after asystole and PEA, children had better outcomes than adults despite fewer cardiac arrests due to VF or pulseless VT.
Age is an important determinant of outcome from adult cardiac arrests but has not been identified previously as an important factor in pediatric cardiac arrests except among premature infants. Chest compressions can result in more effective blood flow during cardiac arrest in an infant than an older child or adult because of increased chest wall compliance. We, therefore, hypothesized that survival from cardiac arrest would be better among infants than older children.
We evaluated 464 pediatric ICU arrests from the National Registry of Cardiopulmonary Resuscitation from 2000 to 2002. NICU cardiac arrests were excluded. Data from each arrest include >200 variables describing facility, patient, prearrest, arrest intervention, outcome, and quality improvement data. Age was categorized as newborn (<1 month; N = 62), infant (1 month to <1 year; N = 105), younger child (1 year to <8 years; N = 90), and older child (8 years to <21 years; N = 207). Multivariable logistic regression was performed to examine the association between age and survival.
Overall survival was 22%, with 27% of newborns, 36% of infants, 19% of younger children and 16% of older children surviving to hospital discharge. Newborns and infants demonstrated double and triple the odds of surviving to hospital discharge from a cardiac arrest in an intensive care setting when compared with older children. When potential confounders were controlled, newborns increased their advantage to almost fivefold, while infants maintained their survival advantage to older children.
Survival from pediatric ICU cardiac arrest is age dependent. Newborns and infants have better survival rates even after adjusting for potential confounding variables.
Cardiopulmonary resuscitation (CPR) quality during actual cardiac arrest has been found to be deficient in several recent investigations. We hypothesized that real-time feedback during CPR would improve the performance of chest compressions and ventilations during in-hospital cardiac arrest.
An investigational monitor/defibrillator with CPR-sensing and feedback capabilities was used during in-hospital cardiac arrests from December 2004 to December 2005. Chest compression and ventilation characteristics were recorded and quantified for the first 5 min of resuscitation and compared to a baseline cohort of arrest episodes without feedback, from December 2002 to April 2004.
Data from 55 resuscitation episodes in the baseline pre-intervention group were compared to 101 resuscitations in the feedback intervention group. There was a trend toward improvement in the mean values of CPR variables in the feedback group with a statistically significant narrowing of CPR variable distributions including chest compression rate (104+/-18 to 100+/-13 min(-1); test of means, p=0.16; test of variance, p=0.003) and ventilation rate (20+/-10 to 18+/-8 min(-1); test of means, p=0.12; test of variance, p=0.04). There were no statistically significant differences between the groups in either return of spontaneous circulation or survival to hospital discharge.
Real-time CPR-sensing and feedback technology modestly improved the quality of CPR during in-hospital cardiac arrest, and may serve as a useful adjunct for rescuers during resuscitation efforts. However, feedback specifics should be optimized for maximal benefit and additional studies will be required to assess whether gains in CPR quality translate to improvements in survival.
Expert guidelines advocate defibrillation within 2 minutes after an in-hospital cardiac arrest caused by ventricular arrhythmia. However, empirical data on the prevalence of delayed defibrillation in the United States and its effect on survival are limited.
We identified 6789 patients who had cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia at 369 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. Using multivariable logistic regression, we identified characteristics associated with delayed defibrillation. We then examined the association between delayed defibrillation (more than 2 minutes) and survival to discharge after adjusting for differences in patient and hospital characteristics.
The overall median time to defibrillation was 1 minute (interquartile range, <1 to 3 minutes); delayed defibrillation occurred in 2045 patients (30.1%). Characteristics associated with delayed defibrillation included black race, noncardiac admitting diagnosis, and occurrence of cardiac arrest at a hospital with fewer than 250 beds, in an unmonitored hospital unit, and during after-hours periods (5 p.m. to 8 a.m. or weekends). Delayed defibrillation was associated with a significantly lower probability of surviving to hospital discharge (22.2%, vs. 39.3% when defibrillation was not delayed; adjusted odds ratio, 0.48; 95% confidence interval, 0.42 to 0.54; P<0.001). In addition, a graded association was seen between increasing time to defibrillation and lower rates of survival to hospital discharge for each minute of delay (P for trend <0.001).
Delayed defibrillation is common and is associated with lower rates of survival after in-hospital cardiac arrest.
Recent investigations have documented poor cardiopulmonary resuscitation (CPR) performance in clinical practice. We hypothesized that a debriefing intervention using CPR quality data from actual in-hospital cardiac arrests (resuscitation with actual performance integrated debriefing [RAPID]) would improve CPR performance and initial patient survival.
Internal medicine residents at a university hospital attended weekly debriefing sessions of the prior week's resuscitations, between March 2006 and February 2007, reviewing CPR performance transcripts obtained from a CPR-sensing and feedback-enabled defibrillator. Objective metrics of CPR performance and initial return of spontaneous circulation were compared with a historical cohort in which a similar feedback-delivering defibrillator was used but without RAPID.
Cardiopulmonary resuscitation quality and outcome data from 123 patients resuscitated during the intervention period were compared with 101 patients in the baseline cohort. Compared with the control period, the mean (SD) ventilation rate decreased (13 [7]/min vs 18 [8]/min; P < .001) and compression depth increased (50 [10] vs 44 [10] mm; P = .001), among other CPR improvements. These changes correlated with an increase in the rate of return of spontaneous circulation in the RAPID group (59.4% vs 44.6%; P = .03) but no change in survival to discharge (7.4% vs 8.9%; P = .69).
The combination of RAPID and real-time audiovisual feedback improved CPR quality compared with the use of feedback alone and was associated with an increased rate of return of spontaneous circulation. Cardiopulmonary resuscitation sensing and recording devices allow for methods of debriefing that were previously available only for simulation-based education; such methods have the potential to fundamentally alter resuscitation training and improve patient outcomes.
clinicaltrials.gov Identifier: NCT00228293.
Background : Incomplete chest recoil during cardiopulmonary resuscitation (CPR) (ie, leaning on the chest during the decompression phase) is purported to decrease venous return, and thereby decrease forward blood flow.
Aim To determine the effect of 10% and 20% lean on hemodynamics during piglet CPR.
Methods : 10 piglets (10.7±1.2 kg) were anesthetized with isoflurane and instrumented with micromanometer-tipped catheters in the right atrium (RA) and aorta (Ao). After induction of ventricular fibrillation, CPR was provided in three-minute epochs with no lean, 10% lean, or 20% lean while aortic systolic pressure (AoS) was targeted at 80–90 mmHg. Because the mean force to attain 80 –90 mm Hg AoS was 18 kg in preliminary studies, 10% and 20% lean were provided as 1.8 and 3.6 kg weights on the chest, respectively. Left ventricular myocardial blood flow (MBF) and cardiac index (CI) were determined by fluorescent, color-microsphere technique. Statistics: paired t -test and repeated measurement ANOVA for parametric, Wilcoxon Rank Sum Test and Friedman’s ANOVA for non-parametric data.
Results : 10% and 20% lean resulted in higher right atrial diastolic pressure (RAD) and lower coronary perfusion pressure (CPP) than no lean. Hemodynamics were not different with 10% lean vs. 20% lean. Mean 10%–20% lean resulted in substantially lower MBF and CI than no lean (Table ).
Conclusions : 10–20% leaning during CPR increases RAD, decreases CPP, and substantially decreases MBF and CI.
Table
Outcome after cardiac arrest and cardiopulmonary resuscitation is dependent on critical interventions, particularly early defibrillation, effective chest compressions, and advanced life support. Utstein-style definitions and reporting templates have been used extensively in published studies of cardiac arrest, which has led to greater understanding of the elements of resuscitation practice and progress toward international consensus on science and resuscitation guidelines. Despite the development of Utstein templates to standardize research reports of cardiac arrest, international registries have yet to be developed. In April 2002, a task force of the International Liaison Committee on Resuscitation (ILCOR) met in Melbourne, Australia, to review worldwide experience with the Utstein definitions and reporting templates. The task force revised the core reporting template and definitions by consensus. Care was taken to build on previous definitions, changing data elements and operational definitions only on the basis of published data and experience derived from those registries that have used Utstein-style reporting. Attention was focused on decreasing the complexity of the existing templates and addressing logistical difficulties in collecting specific core and supplementary (ie, essential and desirable) data elements recommended by previous Utstein consensus conferences. Inconsistencies in terminology between in-hospital and out-of-hospital Utstein templates were also addressed. The task force produced a reporting tool for essential data that can be used for both quality improvement (registries) and research reports and that should be applicable to both adults and children. The revised and simplified template includes practical and succinct operational definitions. It is anticipated that the revised template will enable better and more accurate completion of all reports of cardiac arrest and resuscitation attempts. Problems with data definition, collection, linkage, confidentiality, management, and registry implementation are acknowledged and potential solutions offered. Uniform collection and tracking of registry data should enable better continuous quality improvement within every hospital, emergency medical services system, and community.
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.
Background:
Despite ongoing efforts to improve the quality of pediatric resuscitation, it remains unknown whether survival in children with in-hospital cardiac arrest has improved.
Methods and results:
Between 2000 and 2009, we identified children (<18 years of age) with an in-hospital cardiac arrest at hospitals with >3 years of participation and >5 cases annually within the national Get With The Guidelines-Resuscitation registry. Multivariable logistic regression was used to examine temporal trends in survival to discharge. We also explored whether trends in survival were attributable to improvement in acute resuscitation or postresuscitation care and examined trends in neurological disability among survivors. Among 1031 children at 12 hospitals, the initial cardiac arrest rhythm was asystole and pulseless electrical activity in 874 children (84.8%) and ventricular fibrillation and pulseless ventricular tachycardia in 157 children (15.2%), with an increase in cardiac arrests due to pulseless electrical activity over time (P for trend <0.001). Risk-adjusted rates of survival to discharge increased from 14.3% in 2000 to 43.4% in 2009 (adjusted rate ratio per year, 1.08; 95% confidence interval, 1.01-1.16; P for trend=0.02). Improvement in survival was driven largely by an improvement in acute resuscitation survival (risk-adjusted rates: 42.9% in 2000, 81.2% in 2009; adjusted rate ratio per year: 1.04; 95% confidence interval, 1.01-1.08; P for trend=0.006). Moreover, survival trends were not accompanied by higher rates of neurological disability among survivors over time (unadjusted P for trend=0.32), suggesting an overall increase in the number of survivors without neurological disability over time.
Conclusions:
Rates of survival to hospital discharge in children with in-hospital cardiac arrests have improved over the past decade without higher rates of neurological disability among survivors.
Aim:
To evaluate the association between cardiopulmonary resuscitation (CPR) quality and hemodynamic measurements during in-hospital pediatric cardiac arrest. We hypothesized that AHA recommended CPR rate and depth targets would be associated with systolic blood pressures≥80mmHg and diastolic blood pressures≥30mmHg.
Methods:
In children and adolescents <18 years of age who suffered a cardiac arrest with an invasive arterial catheter in place, a CPR monitoring defibrillator collected CPR data which was synchronized to arterial blood pressure (BP) tracings. Chest compression (CC) depths were corrected for mattress deflection. Generalized least squares regression estimated the association between BP and CPR quality, treated as continuous variables. Mixed-effects logistic regression estimated the association between systolic BP≥80mmHg/diastolic BP≥30mmHg and the AHA targets of depth≥38mm and/or rate≥100/min.
Results:
Nine arrests resulted in 4156 CCs. The median mattress corrected depth was 32mm (IQR 28-38); median rate was 111CC/min (IQR 103-120). AHA depth was achieved in 1090/4156 (26.2%) CCs; rate in 3441 (83.7%). Systolic BP≥80mmHg was attained in 2516/4156 (60.5%) compressions; diastolic≥30mmHg in 2561/4156 (61.6%). A rate≥100/min was associated with systolic BP≥80mmHg (OR 1.32; CI(95) 1.04, 1.66; p=0.02) and diastolic BP≥30mmHg (OR 2.15; CI(95) 1.65, 2.80; p<0.001). Exceeding both (rate≥100/min and depth≥38mm) was associated with systolic BP≥80mmHg (OR 2.02; CI(95) 1.45, 2.82; p<0.001) and diastolic BP≥30mmHg (OR 1.48; CI(95) 1.01, 2.15; p=0.042).
Conclusions:
AHA quality targets (rate≥100/min and depth≥38mm) were associated with systolic BPs≥80mmHg and diastolic BPs≥30mmHg during CPR in children.
Background:
During in-hospital cardiac arrests, how long resuscitation attempts should be continued before termination of efforts is unknown. We investigated whether duration of resuscitation attempts varies between hospitals and whether patients at hospitals that attempt resuscitation for longer have higher survival rates than do those at hospitals with shorter durations of resuscitation efforts.
Methods:
Between 2000 and 2008, we identified 64,339 patients with cardiac arrests at 435 US hospitals within the Get With The Guidelines—Resuscitation registry. For each hospital, we calculated the median duration of resuscitation before termination of efforts in non-survivors as a measure of the hospital's overall tendency for longer attempts. We used multilevel regression models to assess the association between the length of resuscitation attempts and risk-adjusted survival. Our primary endpoints were immediate survival with return of spontaneous circulation during cardiac arrest and survival to hospital discharge.
Findings:
31,198 of 64,339 (48·5%) patients achieved return of spontaneous circulation and 9912 (15·4%) survived to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 min (IQR 6-21) compared with 20 min (14-30) for non-survivors. Compared with patients at hospitals in the quartile with the shortest median resuscitation attempts in non-survivors (16 min [IQR 15-17]), those at hospitals in the quartile with the longest attempts (25 min [25-28]) had a higher likelihood of return of spontaneous circulation (adjusted risk ratio 1·12, 95% CI 1·06-1·18; p<0·0001) and survival to discharge (1·12, 1·02-1·23; 0·021).
Interpretation:
Duration of resuscitation attempts varies between hospitals. Although we cannot define an optimum duration for resuscitation attempts on the basis of these observational data, our findings suggest that efforts to systematically increase the duration of resuscitation could improve survival in this high-risk population.
Funding:
American Heart Association, Robert Wood Johnson Foundation Clinical Scholars Program, and the National Institutes of Health.
Guidelines for cardiopulmonary resuscitation recommend a chest compression rate of at least 100 compressions per minute. Animal and human studies have reported that blood flow is greatest with chest compression rates near 120/min, but few have reported rates used during out-of-hospital (OOH) cardiopulmonary resuscitation or the relationship between rate and outcome. The purpose of this study was to describe chest compression rates used by emergency medical services providers to resuscitate patients with OOH cardiac arrest and to determine the relationship between chest compression rate and outcome.
Included were patients aged ≥ 20 years with OOH cardiac arrest treated by emergency medical services providers participating in the Resuscitation Outcomes Consortium. Data were abstracted from monitor-defibrillator recordings during cardiopulmonary resuscitation. Multiple logistic regression analysis assessed the association between chest compression rate and outcome. From December 2005 to May 2007, 3098 patients with OOH cardiac arrest were included in this study. Mean age was 67 ± 16 years, and 8.6% survived to hospital discharge. Mean compression rate was 112 ± 19/min. A curvilinear association between chest compression rate and return of spontaneous circulation was found in cubic spline models after multivariable adjustment (P=0.012). Return of spontaneous circulation rates peaked at a compression rate of ≈ 125/min and then declined. Chest compression rate was not significantly associated with survival to hospital discharge in multivariable categorical or cubic spline models.
Chest compression rate was associated with return of spontaneous circulation but not with survival to hospital discharge in OOH cardiac arrest.
Objective:
Globally, one third of deaths each year are from cardiovascular diseases, yet no strong evidence supports any specific method of CPR instruction in a resource-limited setting. We hypothesized that both existing and novel CPR training programs significantly impact skills of hospital-based healthcare providers (HCP) in Botswana.
Methods:
HCP were prospectively randomized to 3 training groups: instructor led, limited instructor with manikin feedback, or self-directed learning. Data was collected prior to training, immediately after and at 3 and 6 months. Excellent CPR was prospectively defined as having at least 4 of 5 characteristics: depth, rate, release, no flow fraction, and no excessive ventilation. GEE was performed to account for within subject correlation.
Results:
Of 214 HCP trained, 40% resuscitate ≥ 1/month, 28% had previous formal CPR training, and 65% required additional skills remediation to pass using AHA criteria. Excellent CPR skill acquisition was significant (infant: 32% vs. 71%, p<0.01; adult 28% vs. 48%, p<0.01). Infant CPR skill retention was significant at 3 (39% vs. 70%, p<0.01) and 6 months (38% vs. 67%, p<0.01), and adult CPR skills were retained to 3 months (34% vs. 51%, p=0.02). On multivariable analysis, low cognitive score and need for skill remediation, but not instruction method, impacted CPR skill performance.
Conclusions:
HCP in resource-limited settings resuscitate frequently, with little CPR training. Using existing training, HCP acquire and retain skills, yet often require remediation. Novel techniques with increased student: instructor ratio and feedback manikins were not different compared to traditional instruction.
Debriefing is a process involving the active participation of learners, guided by a facilitator or instructor whose primary goal is to identify and close gaps in knowledge and skills. A review of existing research and a process for identifying future opportunities was undertaken.
A selective critical review of the literature on debriefing in simulation-based education was done. An iterative process of analysis, gathering input from audience participants, and consensus-based synthesis was conducted.
Research is sparse and limited in presentation for all important topic areas where debriefing is a primary variable. The importance of a format for reporting data on debriefing in a research context was realized and a "who, when, where, what, why" approach was proposed. Also, a graphical representation of the characteristics of debriefing studies was developed (Sim-PICO) to help guide simulation researchers in appropriate experimental design and reporting.
A few areas of debriefing practice where obvious gaps that deserve study were identified, such as comparing debriefing techniques, comparing trained versus untrained debriefers, and comparing the effect of different debriefing venues and times. A model for publication of research data was developed and presented which should help researchers clarify methodology in future work.
Our primary objective was to describe and determine the feasibility of implementing a care environment targeted pediatric post-cardiac arrest debriefing program. A secondary objective was to evaluate the usefulness of debriefing content items. We hypothesized that a care environment targeted post-cardiac arrest debriefing program would be feasible, well-received, and result in improved self-reported knowledge, confidence and performance of pediatric providers.
Physician-led multidisciplinary pediatric post-cardiac arrest debriefings were conducted using data from CPR recording defibrillators/central monitors followed by a semi-quantitative survey. Eight debriefing content elements divided, a priori, into physical skill (PS) related and cognitive skill (CS) related categories were evaluated on a 5-point Likert scale to determine those most useful (5-point Likert scale: 1=very useful/5=not useful). Summary scores evaluated the impact on providers' knowledge, confidence, and performance.
Between June 2010 and May 2011, 6 debriefings were completed. Thirty-four of 50 (68%) front line care providers attended the debriefings and completed surveys. All eight content elements were rated between useful to very useful (Median 1; IQR 1-2). PS items scored higher than CS items to improve knowledge (Median: 2 (IQR 1-3) vs. 1 (IQR 0-2); p<0.02) and performance (Median: 2 (IQR 1-3) vs. 1 (IQR 0-1); p<0.01).
A novel care environment targeted pediatric post-cardiac arrest pediatric debriefing program is feasible and useful for providers regardless of their participation in the resuscitation. Physical skill related elements were rated more useful than cognitive skill related elements for knowledge and performance.
The 2010 international guidelines for cardiopulmonary resuscitation recently recommended an increase in the minimum compression depth from 38 to 50 mm, although there are limited human data to support this. We sought to study patterns of cardiopulmonary resuscitation compression depth and their associations with patient outcomes in out-of-hospital cardiac arrest cases treated by the 2005 guideline standards.
Prospective cohort.
Seven U.S. and Canadian urban regions.
We studied emergency medical services treated out-of-hospital cardiac arrest patients from the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest for whom electronic cardiopulmonary resuscitation compression depth data were available, from May 2006 to June 2009.
We calculated anterior chest wall depression in millimeters and the period of active cardiopulmonary resuscitation (chest compression fraction) for each minute of cardiopulmonary resuscitation. We controlled for covariates including compression rate and calculated adjusted odds ratios for any return of spontaneous circulation, 1-day survival, and hospital discharge.
We included 1029 adult patients from seven U.S. and Canadian cities with the following characteristics: Mean age 68 yrs; male 62%; bystander witnessed 40%; bystander cardiopulmonary resuscitation 37%; initial rhythms: Ventricular fibrillation/ventricular tachycardia 24%, pulseless electrical activity 16%, asystole 48%, other nonshockable 12%; outcomes: Return of spontaneous circulation 26%, 1-day survival 18%, discharge 5%. For all patients, median compression rate was 106 per minute, median compression fraction 0.65, and median compression depth 37.3 mm with 52.8% of cases having depth <38 mm and 91.6% having depth <50 mm. We found an inverse association between depth and compression rate ( p < .001). Adjusted odds ratios for all depth measures (mean values, categories, and range) showed strong trends toward better outcomes with increased depth for all three survival measures.
We found suboptimal compression depth in half of patients by 2005 guideline standards and almost all by 2010 standards as well as an inverse association between compression depth and rate. We found a strong association between survival outcomes and increased compression depth but no clear evidence to support or refute the 2010 recommendations of >50 mm. Although compression depth is an important component of cardiopulmonary resuscitation and should be measured routinely, the most effective depth is currently unknown.
The incidence and incidence over time of cardiac arrest in hospitalized patients is unknown. We sought to estimate the event rate and temporal trends of adult inhospital cardiac arrest treated with a resuscitation response.
Three approaches were used to estimate the inhospital cardiac arrest event rate. First approach: calculate the inhospital cardiac arrest event rate at hospitals (n = 433) in the Get With The Guidelines-Resuscitation registry, years 2003-2007, and multiply this by U.S. annual bed days. Second approach: use the Get With The Guidelines-Resuscitation inhospital cardiac arrest event rate to develop a regression model (including hospital demographic, geographic, and organizational factors), and use the model coefficients to calculate predicted event rates for acute care hospitals (n = 5445) responding to the American Hospital Association survey. Third approach: classify acute care hospitals into groups based on academic, urban, and bed size characteristics, and determine the average event rate for Get With The Guidelines-Resuscitation hospitals in each group, and use weighted averages to calculate the national inhospital cardiac arrest rate. Annual event rates were calculated to estimate temporal trends.
Get With The Guidelines-Resuscitation registry.
Adult inhospital cardiac arrest with a resuscitation response.
The mean adult treated inhospital cardiac arrest event rate at Get With The Guidelines-Resuscitation hospitals was 0.92/1000 bed days (interquartile range 0.58 to 1.2/1000). In hospitals (n = 150) contributing data for all years of the study period, the event rate increased from 2003 to 2007. With 2.09 million annual U.S. bed days, we estimated 192,000 inhospital cardiac arrests throughout the United States annually. Based on the regression model, extrapolating Get With The Guidelines-Resuscitation hospitals to hospitals participating in the American Hospital Association survey projected 211,000 annual inhospital cardiac arrests. Using weighted averages projected 209,000 annual U.S. inhospital cardiac arrests.
There are approximately 200,000 treated cardiac arrests among U.S. hospitalized patients annually, and this rate may be increasing. This is important for understanding the burden of inhospital cardiac arrest and developing strategies to improve care for hospitalized patients.
Perishock pauses are pauses in chest compressions before and after defibrillatory shock. We examined the relationship between perishock pauses and survival to hospital discharge.
We included out-of-hospital cardiac arrest patients in the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest who suffered arrest between December 2005 and June 2007, presented with a shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia), and had cardiopulmonary resuscitation process data for at least 1 shock (n=815). We used multivariable logistic regression to determine the association between survival and perishock pauses. In an analysis adjusted for Utstein predictors of survival, the odds of survival were significantly lower for patients with preshock pause ≥20 seconds (odds ratio, 0.47; 95% confidence interval, 0.27 to 0.82) and perishock pause ≥40 seconds (odds ratio, 0.54; 95% confidence interval, 0.31 to 0.97) compared with patients with preshock pause <10 seconds and perishock pause <20 seconds. Postshock pause was not independently associated with a significant change in the odds of survival. Log-linear modeling depicted a decrease in survival to hospital discharge of 18% and 14% for every 5-second increase in both preshock and perishock pause interval (up to 40 and 50 seconds, respectively), with no significant association noted with changes in the postshock pause interval.
In patients with cardiac arrest presenting in a shockable rhythm, longer perishock and preshock pauses were independently associated with a decrease in survival to hospital discharge. The impact of preshock pause on survival suggests that refinement of automatic defibrillator software and paramedic education to minimize preshock pause delays may have a significant impact on survival.
Vasopressors administered IV late during resuscitation efforts fail to improve survival. Intraosseous (IO) access can provide a route for earlier administration. We hypothesized that IO epinephrine after 1 minute of cardiopulmonary resuscitation (CPR) (an "optimal" IO scenario) after 10 minutes of untreated ventricular fibrillation (VF) cardiac arrest would improve outcome in comparison with either IV epinephrine after 8 minutes of CPR (a "realistic" IV scenario) or placebo controls with no epinephrine.
Thirty swine were randomized to IO epinephrine, IV epinephrine, or placebo. Important outcomes included return of spontaneous circulation (ROSC), 24-hour survival, and 24-hour survival with good neurological outcome (cerebral performance category 1).
ROSC after 10 minutes of untreated VF was uncommon without administration of epinephrine (1 of 10), whereas ROSC was nearly universal with IO epinephrine or delayed IV epinephrine (10 of 10 and 9 of 10, respectively; P = 0.001 for either versus placebo). Twenty-four hour survival was substantially more likely after IO epinephrine than after delayed IV epinephrine (10 of 10 vs. 4 of 10, P = 0.001). None of the placebo group survived at 24 hours. Survival with good neurological outcome was more likely after IO epinephrine than after placebo (6 of 10 vs. 0 of 10, P = 0.011), and only 3 of 10 survived with good neurological outcome in the delayed IV epinephrine group (not significant versus either IO or placebo).
In this swine model of prolonged VF cardiac arrest, epinephrine administration during CPR improved outcomes. In addition, early IO epinephrine improved outcomes in comparison with delayed IV epinephrine.
Resuscitation guidelines recommend rescue ventilations consist of tidal volumes 7-10 ml/kg. Changes in thoracic impedance (ΔTI) measured using defibrillator electrode pads to detect and guide rescue ventilations have not been studied in children.
We hypothesized that ΔTI measured via standard anterior-apical (AA) position can accurately detect ventilations with volume > 7 ml/kg in children. We also compared standard AA position with alternative anterior-posterior (AP) position.
IRB-approved, prospective, observational study of sedated, subjects (6 months to 17 years) on conventional mechanical ventilation. Thoracic impedance (TI) was obtained via Philips MRx defibrillator with standard electrode pads for 5 min each in AA and AP positions. Ventilations were simultaneously measured by pneumotachometer (Novametrix CO(2)SMO Plus).
Twenty-eight subjects (median 4 years, IQR 1.7-9 years; median 16.3 kg, IQR 10.5-39 kg) were enrolled. Data were available for 21 episodes in AA position and 22 episodes in AP position, with paired AA and AP data available for 18. For ventilations with volume < 7 ml/kg, the defibrillator algorithm detected 80.0% for both AA and AP (p=0.99). For ventilations ≥ 7 ml/kg, detection was 95.1% for AA and 95.7% for AP (p=0.38).
Changes in thoracic impedance obtained via defibrillator pads can accurately detect ventilations above 7 ml/kg in stable, mechanically ventilated children, corresponding to rescue ventilations recommended during CPR. Both AA and AP pad positions were less sensitive to detect smaller volumes (< 7 ml/kg) than higher volumes (≥ 7 ml/kg), suggesting that shallow ventilations during CPR might be missed. There were no differences in impedance measurements between standard AA pad position and commonly used alternative AP pad position.
To investigate the effectiveness of brief bedside "booster" cardiopulmonary resuscitation (CPR) training to improve CPR guideline compliance of hospital-based pediatric providers.
Prospective, randomized trial.
General pediatric wards at Children's Hospital of Philadelphia.
Sixty-nine Basic Life Support-certified hospital-based providers.
CPR recording/feedback defibrillators were used to evaluate CPR quality during simulated pediatric arrest. After a 60-sec pretraining CPR evaluation, subjects were randomly assigned to one of three instructional/feedback methods to be used during CPR booster training sessions. All sessions (training/CPR manikin practice) were of equal duration (2 mins) and differed only in the method of corrective feedback given to participants during the session. The study arms were as follows: 1) instructor-only training; 2) automated defibrillator feedback only; and 3) instructor training combined with automated feedback.
Before instruction, 57% of the care providers performed compressions within guideline rate recommendations (rate >90 min(-1) and <120 min(-1)); 71% met minimum depth targets (depth, >38 mm); and 36% met overall CPR compliance (rate and depth within targets). After instruction, guideline compliance improved (instructor-only training: rate 52% to 87% [p .01], and overall CPR compliance, 43% to 78% [p < .02]; automated feedback only: rate, 70% to 96% [p = .02], depth, 61% to 100% [p < .01], and overall CPR compliance, 35% to 96% [p < .01]; and instructor training combined with automated feedback: rate 48% to 100% [p < .01], depth, 78% to 100% [p < .02], and overall CPR compliance, 30% to 100% [p < .01]).
Before booster CPR instruction, most certified Pediatric Basic Life Support providers did not perform guideline-compliant CPR. After a brief bedside training, CPR quality improved irrespective of training content (instructor vs. automated feedback). Future studies should investigate bedside training to improve CPR quality during actual pediatric cardiac arrests.
Complete recoil of the chest wall between chest compressions during cardiopulmonary resuscitation is recommended, because incomplete chest wall recoil from leaning may decrease venous return and thereby decrease blood flow. We evaluated the hemodynamic effect of 10% or 20% lean during piglet cardiopulmonary resuscitation.
Prospective, sequential, controlled experimental animal investigation.
University research laboratory.
Domestic piglets.
After induction of ventricular fibrillation, cardiopulmonary resuscitation was provided to ten piglets (10.7 +/- 1.2 kg) for 18 mins as six 3-min epochs with no lean, 10% lean, or 20% lean to maintain aortic systolic pressure of 80-90 mm Hg. Because the mean force to attain 80-90 mm Hg was 18 kg in preliminary studies, the equivalent of 10% and 20% lean was provided by use of 1.8- and 3.6-kg weights on the chest.
Using a linear mixed-effect regression model to control for changes in cardiopulmonary resuscitation hemodynamics over time, mean right atrial diastolic pressure was 9 +/- 0.6 mm Hg with no lean, 10 +/- 0.3 mm Hg with 10% lean (p < .01), and 13 +/- 0.3 mm Hg with 20% lean (p < .01), resulting in decreased coronary perfusion pressure with leaning. Microsphere-determined cardiac index and left ventricular myocardial blood flow were lower with 10% and 20% leaning throughout the 18 mins of cardiopulmonary resuscitation. Mean cardiac index decreased from 1.9 +/- 0.2 L . M . min with no leaning to 1.6 +/- 0.1 L . M . min with 10% leaning, and 1.4 +/- 0.2 L . M . min with 20% leaning (p < .05). The myocardial blood flow decreased from 39 +/- 7 mL . min . 100 g with no lean to 30 +/- 6 mL . min . 100 g with 10% leaning and 26 +/- 6 mL . min . 100 g with 20% leaning (p < .05).
Leaning of 10% to 20% (i.e., 1.8-3.6 kg) during cardiopulmonary resuscitation substantially decreased coronary perfusion pressure, cardiac index, and myocardial blood flow.
The objective of this study was to assess whether pediatric inpatients who receive cardiopulmonary resuscitation (CPR) for bradycardia with poor perfusion are more likely to survive to hospital discharge than pediatric inpatients who receive CPR for pulseless arrest (asystole/pulseless electrical activity [PEA]), after controlling for confounding characteristics.
A prospective cohort from the National Registry of Cardiopulmonary Resuscitation was enrolled between January 4, 2000, and February 23, 2008. Patients who were younger than 18 years and had an in-hospital event that required chest compressions for >2 minutes were eligible. Patients were divided into 2 groups on the basis of initial rhythm and pulse state: bradycardia/poor perfusion and asystole/PEA. Patient characteristics, event characteristics, and clinical characteristics were analyzed as possible confounders. Univariate analysis between bradycardia and asystole/PEA patient groups was performed. Multivariable logistic regression was used to determine whether an initial state of bradycardia/poor perfusion was independently associated with survival to discharge.
A total of 6288 patients who were younger than 18 years were reported; 3342 met all inclusion criteria. A total of 1853 (55%) patients received chest compressions for bradycardia/poor perfusion compared with 1489 (45%) for asystole/PEA. Overall, 755 (40.7%) of 1353 patients with bradycardia survived to hospital discharge, compared with 365 (24.5%) of 1489 patients with asystole/PEA. After controlling for known confounders, CPR for bradycardia with poor perfusion was associated with increased survival to hospital discharge.
Pediatric inpatients with chest compressions initiated for bradycardia and poor perfusion before onset of pulselessness were more likely to survive to discharge than pediatric inpatients with chest compressions initiated for asystole or PEA.
Quality cardiopulmonary resuscitation contributes to cardiac arrest survival. The proportion of time in which chest compressions are performed in each minute of cardiopulmonary resuscitation is an important modifiable aspect of quality cardiopulmonary resuscitation. We sought to estimate the effect of an increasing proportion of time spent performing chest compressions during cardiac arrest on survival to hospital discharge in patients with out-of-hospital ventricular fibrillation or pulseless ventricular tachycardia.
This is a prospective observational cohort study of adult patients from the Resuscitation Outcomes Consortium Cardiac Arrest Epistry with confirmed ventricular fibrillation or ventricular tachycardia, no defibrillation before emergency medical services arrival, electronically recorded cardiopulmonary resuscitation before the first shock, and a confirmed outcome. Patients were followed up to discharge from the hospital or death. Of the 506 cases, the mean age was 64 years, 80% were male, 71% were witnessed by a bystander, 51% received bystander cardiopulmonary resuscitation, 34% occurred in a public location, and 23% survived. After adjustment for age, gender, location, bystander cardiopulmonary resuscitation, bystander witness status, and response time, the odds ratios of surviving to hospital discharge in the 2 highest categories of chest compression fraction compared with the reference category were 3.01 (95% confidence interval 1.37 to 6.58) and 2.33 (95% confidence interval 0.96 to 5.63). The estimated adjusted linear effect on odds ratio of survival for a 10% change in chest compression fraction was 1.11 (95% confidence interval 1.01 to 1.21).
An increased chest compression fraction is independently predictive of better survival in patients who experience a prehospital ventricular fibrillation/tachycardia cardiac arrest.
High quality CPR skill retention is poor. We hypothesized that "just-in-time" and "just-in-place" training programs would be effective and well-accepted to maintain CPR skills among PICU staff.
"Rolling Refreshers", a portable manikin/defibrillator system with chest compression sensor providing automated corrective feedback to optimize CPR skills, were conducted daily in the PICU with multidisciplinary healthcare providers. Providers practiced CPR until skill success was attained, prospectively defined as <3 corrective prompts within 30s targeting chest compression (CC) rate 90-120/min, CC depth > 38 mm during continuous CPR. Providers completing > or =2 refreshers/month (Frequent Refreshers [FR]) were compared to providers completing < 2 refreshers/month (Infrequent Refreshers [IR]) for time to achieve CPR skill success. Univariate analysis performed using non-parametric methods. Following actual cardiac arrests, CPR providers were surveyed for subjective feedback on training approach efficacy (5-point Likert scale; 1=poor to 5=excellent).
Over 15 weeks, 420 PICU staff were "refreshed": 340 nurses, 34 physicians, 46 respiratory therapists. A consecutive sample of 20 PICU staff was assessed before subsequent refresher sessions (FREQ n=10, INFREQ n=10). Time to achieve CPR skill success was significantly less in FREQ (median 21s, IQR: 15.75-30s) than in INFREQ (median 67s, IQR: 41.5-84s; p<0.001). Following actual resuscitations, CPR providers (n=9) rated "Rolling Refresher" training as effective (mean=4.2; Likert scale 1-5; standard deviation 0.67).
A novel "Rolling Refresher" CPR skill training approach using "just-in-time" and "just-in-place" simulation is effective and well received by PICU staff. More frequent refreshers resulted in significantly shorter times to achieve proficient CPR skills.
Appropriate chest compression (CC) depth is associated with improved CPR outcome. CCs provided in hospital are often conducted on a compliant mattress. The objective was to quantify the effect of mattress compression on the assessment of CPR quality in children.
A force and deflection sensor (FDS) was used during CPR in the Pediatric Intensive Care Unit and Emergency Department of a children's hospital. The sensor was interposed between the chest of the patient and hands of the rescuer and measured CC depth. Following CPR event, each event was reconstructed with a manikin and an identical mattress/backboard/patient configuration. CCs were performed using FDS on the sternum and a reference accelerometer attached to the spine of the manikin, providing a means to calculate the mattress deflection.
Twelve CPR events with 14,487 CC (11 patients, median age 14.9 years) were recorded and reconstructed: 9 on ICU beds (9296 CC), 3 on stretchers (5191 CC). Measured mean CC depth during CPR was 47+/-8mm on ICU beds, and 45+/-7 mm on stretcher beds with overestimation of 13+/-4mm and 4+/-1mm, respectively, due to mattress compression. After adjusting for this, the proportion of CC that met the CPR guidelines decreased from 88.4 to 31.8% on ICU beds (p<0.001), and 86.3 to 64.7% on stretcher (p<0.001). The proportion of appropriate depth CC was significantly smaller on ICU beds (p<0.001).
CC conducted on a non-rigid surface may not be deep enough. FDS may overestimate CC depth by 28% on ICU beds, and 10% on stretcher beds.
To determine the effect of a medical emergency team (MET) on the incidence of unexpected cardiac arrest and death.
Comparison of retrospective data (pre-MET) before introduction of MET with prospective data after introduction of MET system (post-MET).
Tertiary care pediatric hospital.
A total of 104,780 admissions during a 41-month period pre-MET; 138,424 admissions during 48 months post-MET.
Introduction of a MET.
Total hospital deaths decreased from 4.38 to 2.87/ 1000 admissions (risk ratio 0.65, 95% confidence interval [CI] 0.57-0.75, p < 0.0001). Ward unexpected death decreased from 13 (0.12/1000) to 6 (0.04/1000) (risk ratio 0.35, 95% CI 0.13- 0.92, p = 0.03) but unexpected cardiac arrests did not change from 0.19/1000 to 0.17/1000 (risk ratio 0.91, 95% CI 0.50 -1.64, p = 0.75). Thirty-four hospital deaths, including three unexpected deaths (1 out of 72 MET calls), were prevented each year of MET operation. Preventable cardiac arrest (children whose symptoms or signs fulfilled MET calling criteria) decreased from 17 (0.16/ 1000) to 10 (0.07/1000) (risk ratio 0.45, 95% CI 0.20-0.97, p = 0.04) and in whom death decreased from 12 to 2 (0.11/1000 to 0.01/1000) (risk ratio 0.13, 95% CI 0.03-0.56, p = 0.001). Nonpreventable cardiac arrest (children whose symptoms or signs did not fulfill MET calling criteria) increased from 3 to 14 (0.03/1000 to 0.10/1000, p = 0.03) but death did not increase. Survival from cardiac arrest increased from 7 of 20 patients to 17 of 23 (risk ratio 2.11, 95% CI 1.11- 4.02, p = 0.01). Annual calls for urgent assistance were 202 in the post-MET era and 46 during the pre-MET era (ratio 4.4:1).
Introduction of a MET was associated with reduction of total hospital death and reduction of preventable cardiac arrest and death with increased survival in wards of a pediatric hospital. MET calling criteria identified some but not all children at risk of unexpected cardiac arrest and death.
The aim of this paper is to critically review what is felt to be important about the role of debriefing in the field of simulation-based learning, how it has come about and developed over time, and the different styles or approaches that are used and how effective the process is. A recent systematic review of high fidelity simulation literature identified feedback (including debriefing) as the most important feature of simulation-based medical education. 1 Despite this, there are surprisingly few papers in the peer-reviewed literature to illustrate how to debrief, how to teach or learn to debrief, what methods of debriefing exist and how effective they are at achieving learning objectives and goals. This review is by no means a systematic review of all the literature available on debriefing, and contains information from both peer and nonpeer reviewed sources such as meeting abstracts and presentations from within the medical field and other disciplines versed in the practice of debriefing such as military, psychology, and business. It also contains many examples of what expert facilitators have learned over years of practice in the area. We feel this would be of interest to novices in the field as an introduction to debriefing, and to experts to illustrate the gaps that currently exist, which might be addressed in further research within the medical simulation community and in collaborative ventures between other disciplines experienced in the art of debriefing.
Twelve adult (nine men and three women) cardiac arrest patients were studied as they received CPR by a computerized Thumper to determine the influence of the applied chest compression force on blood flow (as assessed by the end-tidal carbon dioxide concentration) and arterial pressure. At the end of a resuscitation when the decision was made by the senior physician to cease resuscitative efforts, the applied force on the CPR Thumper was decreased from 140 to 0 pound-force (lbf) in 20-lbf increments at 30-second intervals. Radial artery cutdown blood pressure and end-tidal carbon dioxide (ETCO2) were recorded continuously. Arterial systolic blood pressure was linearly related (r = .59, P less than .0001) to applied force (systolic blood pressure, 31 +/- 6 mm Hg at 20 lbf to 60 +/- 7 mm Hg at 140 lbf). ETCO2 (r = .42, P less than .0001) was also linearly related to applied force (ETCO2, 0.7 +/- 0.1% at 20 lbf to 1.5 +/- 0.2% at 140 lbf). Diastolic pressure did not change significantly with change in applied force (17 +/- 2 mm Hg from 20 to 140 lbf). Our findings indicate that higher compression force than that currently recommended may improve arterial systolic pressure and flow in human beings receiving closed-chest compression during CPR.
The optimal rate of chest compression during CPR in man has been debated. Recently, the end-tidal carbon dioxide concentration (PetCO2) has been shown to correlate with cardiac output during CPR in experimental animals. Eighteen prehospital cardiac arrest patients were studied to determine the effect of external chest compression rate on the PetCO2 and BP in man when ventilation rate, ventilation inspiration time, applied compression force, and a 50:50 downstroke:upstroke ratio were held constant using a microprocessor-controlled CPR Thumper. Compression rate was increased from 60 to 140/min in 20 beat/min increments. The PetCO2 was 1.7 +/- 0.2% at a compression rate of 60/min and did not change significantly at increased rates. Systolic BP fell progressively from 59 +/- 5 mm Hg at 60/min to 46 +/- 4 mm Hg at 140/min. Diastolic BP remained approximately 23 mm Hg at all rates studied. Using a CPR manikin, we found that greater Thumper compression force was necessary to sustain the same sternal displacement and to achieve the same applied sternal pressure when the rate was increased due to a rate-limited fall in the compression duration.
Currently, the American Heart Association (AHA) recommends that physicians be certified in cardiopulmonary resuscitation (CPR) every two years. This study was undertaken to determine the effects of time since training on retention of CPR skills of physicians and to identify at what point performance deteriorates to a level requiring retraining with supervised practice. The physicians' performance of CPR one year or less after training was compared with that of more than one year after training. Thirty-three medical residents who had been taught CPR by the same instructor were tested without warning for one-person CPR on a recording mannikin. Performance was evaluated according to AHA Heartsaver criteria. The data were analyzed by organizing all CPR steps or behavioral objectives into three categories: assessment, skills (which included ventilation and compression), and sequence (which included calls for assistance). The data suggest that the knowledge of CPR sequence remains stable and that assessment improves while skill performance deteriorates after one year. This apparent contradiction in overall CPR performance may relate to the effect of experience. Assessment may improve because of involvement in actual resuscitations in the hospital. Deterioration of skills may reflect the fact that senior residents do not actually perform CPR, but become team leaders and thereby lose their skills, or that poor performance is not corrected in actual "code" situations. If a two-year certification standard is maintained, CPR skill testing at least every 12 months should be considered. If skills have deteriorated, hands-on-practice should be undertaken at that time.
Given the current focus on outcomes, there is a crucial need for easily utilized measures that can effectively quantify morbidity or disability after a child's critical illness or injury. The purpose of this study is to significantly extend the research on two such promising measures: the Pediatric Overall Performance Category (POPC) and the Pediatric Cerebral Performance Category (PCPC).
Cross-sectional analysis of a sample of pediatric intensive care unit (PICU) discharges and a prospective follow-up of this cohort of children.
Arkansas Children's Hospital.
Two hundred children (ranging in age from birth to 21 yrs) discharged from a PICU.
None.
Data were collected at PICU discharge, hospital discharge, and 1- and 6-month follow-up assessments after hospital discharge. Measures utilized included the POPC (at PICU discharge), PCPC (at PICU discharge), Stanford-Binet Intelligence Scale, fourth edition (at hospital discharge), Bayley Scales of Infant Development, second edition (at hospital discharge), and the Vineland Adaptive Behavior Scales (at 1 and 6 months after discharge). Stanford-Binet Intelligence Quotients and Bayley Mental Developmental Index scores were significantly different across PCPC categories (p < .0001). Bayley Psychomotor Developmental Index scores and Vineland Adaptive Behavior Scales scores varied significantly across POPC categories (p < .0001). The test for linear trend was also significant for each of the comparisons.
The results of this study offer additional support for the use of the PCPC and POPC. These brief and easily completed measures can provide useful information regarding probable outcomes for pediatric intensive care patients when more extensive psychometric testing is not feasible or desirable.
Outcome following cardiac arrest and cardiopulmonary resuscitation is dependent on critical interventions, particularly early defibrillation, effective chest compressions, and advanced life support. Utstein-style definitions and reporting templates have been used extensively in published studies of cardiac arrest, which has led to greater understanding of the elements of resuscitation practice and progress toward international consensus on science and resuscitation guidelines. Despite the development of Utstein templates to standardize research reports of cardiac arrest, international registries have yet to be developed. In April 2002 a task force of ILCOR met in Melbourne. Australia, to review worldwide experience with the Utstein definitions and reporting templates. The task force revised the core reporting template and definitions by consensus. Care was taken to build on previous definitions, changing data elements and operational definitions only on the basis of published data and experience derived from those registries that have used Utstein-style reporting. Attention was focused on decreasing the complexity of the existing templates and addressing logistical difficulties in collecting specific core and supplementary (i.e., essential and desirable) data elements recommended by previous Utstein consensus conference. Inconsistencies in terminology between in-hospital and out-of-hospital Utstein templates were also addressed. The task force produced a reporting tool for essential data that can be used for both quality improvement (C) 2004 Published by Elsevier Ireland Ltd.
Recent data highlight a vital link between well-performed cardiopulmonary resuscitation (CPR) and survival after cardiac arrest; however, the quality of CPR as actually performed by trained healthcare providers is largely unknown. We sought to measure in-hospital chest compression rates and to determine compliance with published international guidelines.
We developed and validated a handheld recording device to measure chest compression rate as a surrogate for CPR quality. A prospective observational study of adult cardiac arrests was performed at 3 hospitals from April 2002 to October 2003. Resuscitations were witnessed by trained observers using a customized personal digital assistant programmed to store the exact time of each chest compression, allowing offline calculation of compression rates at serial time points. In 97 arrests, data from 813 minutes during which chest compressions were delivered were analyzed in 30-second time segments. In 36.9% of the total number of segments, compression rates were <80 compressions per minute (cpm), and 21.7% had rates <70 cpm. Higher chest compression rates were significantly correlated with initial return of spontaneous circulation (mean chest compression rates for initial survivors and nonsurvivors, 90+/-17 and 79+/-18 cpm, respectively; P=0.0033).
In-hospital chest compression rates were below published resuscitation recommendations, and suboptimal compression rates in our study correlated with poor return of spontaneous circulation. CPR quality is likely a critical determinant of survival after cardiac arrest, suggesting the need for routine measurement, monitoring, and feedback systems during actual resuscitation.
This paper reports a literature review examining factors that enhance retention of knowledge and skills during and after resuscitation training, in order to identify educational strategies that will optimize survival for victims of cardiopulmonary arrest.
Poor knowledge and skill retention following cardiopulmonary resuscitation training for nursing and medical staff has been documented over the past 20 years. Cardiopulmonary resuscitation training is mandatory for nursing staff and is important as nurses often discover the victims of in-hospital cardiac arrest. Many different methods of improving this retention have been devised and evaluated. However, the content and style of this training lack standardization.
A literature review was undertaken using the Cumulative Index to Nursing and Allied Health Literature, MEDLINE and British Nursing Index databases and the keywords 'cardiopulmonary resuscitation', 'basic life support', 'advanced life support' and 'training'. Papers published between 1992 and 2002 were obtained and their reference lists scrutinized to identify secondary references, of these the ones published within the same 10-year period were also included. Those published in the English language that identified strategies to enhance the acquisition or retention of Cardiopulmonary resuscitation skills and knowledge were included in the review.
One hundred and five primary and 157 secondary references were identified. Of these, 24 met the criteria and were included in the final literature sample. Four studies were found pertaining to cardiac arrest simulation, three to peer tuition, four to video self-instruction, three to the use of different resuscitation guidelines, three to computer-based learning programmes, two to voice-activated manikins, two to automated external defibrillators, one to self-instruction, one to gaming and the one to the use of action cards.
Resuscitation training should be based on in-hospital scenarios and current evidence-based guidelines, including recognition of sick patients, and should be taught using simulations of a variety of cardiac arrest scenarios. This will ensure that the training reflects the potential situations that nurses may face in practice. Nurses in clinical areas, who rarely see cardiac arrests, should receive automated external defibrillation training and have access to defibrillators to prevent delays in resuscitation. Staff should be formally assessed using a manikin with a feedback mechanism or an expert instructor to ensure that chest compressions and ventilations are adequate at the time of training. Remedial training must be provided as often as required. Resuscitation training equipment should be made available at ward/unit level to allow self-study and practice to prevent deterioration between updates. Video self-instruction has been shown to improve competence in resuscitation. An in-hospital scenario-based video should be devised and tested to assess the efficacy of this medium in resuscitation training for nurses.
The objective of this study was to evaluate retention of ALS knowledge and performance among anaesthesiologists, who, in Italy, respond to in-hospital emergencies as team leaders.
47 anaesthesiologists (23 consultants and 24 residents) were invited at one weeks notice to attend a re-evaluation session, 6 months after successful completion of an ERC ALS course. Knowledge retention was assessed by a multiple choice question test, and skills and management by evaluation of performance as team leader in one of the six standardized CAStest scenarios. During the performance, the timeliness of first defibrillation, completion of the three shock sequence, adrenaline (epinephrine) administration and intubation were recorded. Results were compared between consultants and residents.
Compared to the results at the end of the ALS course, the percent of correct answers to the multiple choice question test decreased from 85.89 +/- 5.28% to 79.45 +/- 6.62% (P < 0.001), the number of candidates achieving a pass performance decreased from 47/47 to 30/47 (P < 0.001). Time to first defibrillation was 73.38 +/- 18.72 s, time for completion of the third defibrillation was 113.04 +/- 35.58 s and subsequent ALS interventions were very delayed or forgotten. Comparison between consultants and residents showed that consultants retained knowledge information better, skills decreased comparably in both groups and residents performed tasks faster.
The significant decay of ALS skills 6 months post-ALS recorded among anaesthesiologists supports the need for periodical reinforcement during intervals before recertification.
Ventricular fibrillation and ventricular tachycardia are less common causes of cardiac arrest in children than in adults. These tachyarrhythmias can also begin during cardiopulmonary resuscitation (CPR), presumably as reperfusion arrhythmias. We determined whether the outcome is better for initial than for subsequent ventricular fibrillation or tachycardia.
All cardiac arrests in persons under 18 years of age were identified from a large, multicenter, in-hospital cardiac-arrest registry. The results from children with initial ventricular fibrillation or tachycardia, children in whom ventricular fibrillation or tachycardia developed during CPR, and children with no ventricular fibrillation or tachycardia were compared by chi-square and multivariable logistic-regression analysis.
Of 1005 index patients with in-hospital cardiac arrest, 272 (27 percent) had documented ventricular fibrillation or tachycardia during the arrest. In 104 patients (10 percent), ventricular fibrillation or tachycardia was the initial pulseless rhythm; in 149 patients (15 percent), it developed during the arrest. The time of initiation of ventricular fibrillation or tachycardia was not documented in 19 patients. Thirty-five percent of patients with initial ventricular fibrillation or tachycardia survived to hospital discharge, as compared with 11 percent of patients with subsequent ventricular fibrillation or tachycardia (odds ratio, 2.6; 95 percent confidence interval, 1.2 to 5.8). Twenty-seven percent of patients with no ventricular fibrillation or tachycardia survived to hospital discharge, as compared with 11 percent of patients with subsequent ventricular fibrillation or tachycardia (odds ratio, 3.8; 95 percent confidence interval, 1.8 to 7.6).
In pediatric patients with in-hospital cardiac arrests, survival outcomes were highest among patients in whom ventricular fibrillation or tachycardia was present initially than among those in whom it developed subsequently. The outcomes for patients with subsequent ventricular fibrillation or tachycardia were substantially worse than those for patients with asystole or pulseless electrical activity.
Cardiopulmonary resuscitation (CPR) and electrical defibrillation are the primary treatment options for ventricular fibrillation (VF). While recent studies have shown that providing CPR prior to defibrillation may improve outcomes, the effects of CPR quality remain unclear. Specifically, the clinical effects of compression depth and pauses in chest compression prior to defibrillation (pre-shock pauses) are unknown.
A prospective, multi-center, observational study of adult in-hospital and out-of-hospital cardiac resuscitations was conducted between March 2002 and December 2005. An investigational monitor/defibrillator equipped to measure compression characteristics during CPR was used.
Data were analyzed from 60 consecutive resuscitations in which a first shock was administered for VF. The primary outcome was first shock success defined as removal of VF for at least 5s following defibrillation. A logistic regression analysis demonstrated that successful defibrillation was associated with shorter pre-shock pauses (adjusted odds ratio 1.86 for every 5s decrease; 95% confidence interval 1.10-3.15) and higher mean compression depth during the 30s of CPR preceding the pre-shock pause (adjusted odds ratio 1.99 for every 5mm increase; 95% confidence interval 1.08-3.66).
The quality of CPR prior to defibrillation directly affects clinical outcomes. Specifically, longer pre-shock pauses and shallow chest compressions are associated with defibrillation failure. Strategies to correct these deficiencies should be developed and consideration should be made to replacing current-generation automated external defibrillators that require long pre-shock pauses for rhythm analysis.
To compare quality of CPR during out-of-hospital cardiac arrest with and without automated feedback.
Consecutive adult, out-of-hospital cardiac arrests of all causes were studied. One hundred and seventy-six episodes (March 2002-October 2003) without feedback were compared to 108 episodes (October 2003-September 2004) where automatic feedback on CPR was given. Automated verbal and visual feedback was based on measured quality with a prototype defibrillator. Quality of CPR was the main outcome measure and survival was reported as specified in the protocol.
Average compression depth increased from (mean +/- S.D.) 34 +/- 9 to 38 +/- 6 mm (mean difference (95% CI) 4 (2, 6), P < 0.001), and median percentage of compressions with adequate depth (38-51 mm) increased from 24% to 53% (P < 0.001, Mann-Whitney U-test) with feedback. Mean compression rate decreased from 121 +/- 18 to 109 +/- 12 min(-1) (difference -12 (-16, -9), P = 0.001). There were no changes in the mean number of ventilations per minute; 11 +/- 5 min(-1) versus 11 +/- 4 min(-1) (difference 0 (-1, 1), P = 0.8) or the fraction of time without chest compressions; 0.48 +/- 0.18 versus 0.45 +/- 0.17 (difference -0.03 (-0.08, 0.01), P = 0.08). With intention to treat analysis 7/241 control patients were discharged alive (2.9%) versus 5/117 with feedback (4.3%) (OR 1.5 (95% CI; 0.8, 3), P = 0.2). In a logistic regression analysis of all cases, witnessed arrest (OR 4.2 (95% CI; 1.6, 11), P = 0.004) and average compression depth (per mm increase) (OR 1.05 (95% CI; 1.01, 1.09), P = 0.02) were associated with rate of hospital admission.
Automatic feedback improved CPR quality in this prospective non-randomised study of out-of-hospital cardiac arrest. Increased compression depth was associated with increased short-term survival.
ClinicalTrials.gov (NCT00138996), http://www.clinicaltrials.gov/.