Advanced Resuscitation Training Research Articles

The initiative for medical equity and global health (IMEGH) resuscitation training program: A model for resuscitation training courses in Africa

In high-income countries, outcomes following in hospital cardiac arrest have improved over the last two decades due to the introduction of rapid response teams, cardiac arrest teams, and advanced resuscitation training. However, in low-income countries, such as Rwanda, outcomes are still poor. This is due to multiple factors including lack of adequate resuscitation training, few trainers, and lack of equipment.To address this issue, the Initiative for Medical Equity and Global Health Equity (IMEGH), a training organization founded in 2018 by 5 local anesthesiologists has regularly taught resuscitation courses such as Basic Life Support, Advanced Cardiac Life Support, and Pediatric Advanced Life Support in hospitals throughout Rwanda. The aims of the organization include developing a sustainable model to offer context relevant resuscitation training courses, building a cadre of local instructors to teach on the courses, as well as engaging funding partners to help support the effort. From October 2018 until September 2022, 31 courses were run in 11 hospitals across Rwanda training 1,060 healthcare providers (mainly of non-physician anesthetists, nurses, midwives, and general practitioners). Ongoing challenges include lack of local protocols, inability to tracking resuscitation outcomes, and continued inaccessibility by many healthcare providers. Despite these challenges, the IMEGH program is an example of a successful context-relevant model and has potential to inform the design of resuscitation programs in other similar settings. This article describes the development of the IMEGH program, accomplishments as well as lessons learned, challenges, and next steps for expansion.

Abstract 19115: In-situ Resuscitation Training in Cardiology Procedural Suites

Background: Critical Care Advanced Resuscitation Training (CC-ART) prepares critical care teams for emergency situations through training that occurs in a simulated clinical space. Simulated environments do not always accurately mirror the actual clinical environments. Simulations conducted in the actual clinical environment, also known as in-situ simulation, may overcome some of these challenges. Goal: To explored the impact of in situ, ART simulation in a Cardiac Catheterization Lab (CCL) and an Electrophysiology Lab (EPL) on the staff’s experience, confidence, and communication skills. Method: Key leadership and educator team members collaborated on the in-situ simulation set up. Coordination with Simulation Center and Central Supply Department was completed to arrange for delivery of high-fidelity manikins and training crash cart to the site. A team of physicians and nurse educators created CCL and EPL scenarios for the simulations and wrote a simulation evaluation survey for CCL and EPL nurses and technologists who attended. Results: . Simulations were run by both critical care anesthesiologist and clinical nurse educator. Pre-simulation and post-simulation surveys were collected immediately prior to and after the in-situ simulation. 38 staff completed pre and post surveys. Pre-simulation, 50.00% of staff strongly agreed that they were confident in their ability to care for a decompensated patient based on the prior CC-ART training versus, post-simulation, 84.21% strongly agreed. Pre-simulation, 26.32% strongly agreed that the simulation center training was similar to their actual work experience versus post-simulation, 78.95% agreed the in-situ simulation matched their actual work experience. Pre-simulation, 52.63% strongly agreed that they were confident in their ability to communicate their needs during emergencies or code blue situations versus post-simulation 86.84% agreed. Conclusion: This quality improvement project highlights the effectiveness of in situ resuscitation simulation in improving healthcare professionals' confidence, training realism, and communication skills . Analysis of patient outcomes is needed to determine the effectiveness and duration of impact of in situ training for clinical practice.

Systematic basic and advanced resuscitation training in medical students and fellows: a proposal from the Working Group on Cardiovascular Urgences and Emergencies of the Italian Society of Cardiology.

Sudden cardiac arrest is a leading cause of death in Europe. High-quality cardiopulmonary resuscitation (CPR) and guidelines compliance of rescuers have been associated with better outcomes after cardiac arrest. However, wide variability in attempting bystander CPR manoeuvres has been reported. Educational programmes for teaching CPR to medical students and fellows are highly advisable in this context. However, there is no homogeneity regarding the CPR education offered by academic institutions. We surveyed 208 Italian medical students and 162 fellows in cardiology regarding the educational offer and needs in CPR. Among the 11 medical schools surveyed, 8 (73%) offer basic (BLS) courses but only 3 (38%) with formal certification of 'BLS provider', while none offers advanced (ACLS/ALS) courses. Among the 30 specialization schools in cardiology surveyed, 10 (33%) offer a BLS course (6 with formal certification of 'BLS provider'), and 8 (27%) offer an ACLS/ALS course (5 with formal certification). Only a minority of students and fellows perceive themselves as highly proficient either in BLS or ACLS/ALS, although most of the fellows were involved at least once in rescuing a cardiac arrest. The present position paper analyses and suggests the strategies that should be adopted by Italian medical and specialization schools to spread the CPR culture and increase the long-standing retention of CPR-related technical and nontechnical skills.

Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Use of a simulation-based advanced resuscitation training curriculum: Impact on cardiopulmonary resuscitation quality and patient outcomes.

Despite a continued focus on improved cardiopulmonary resuscitation quality, survival remains low from in-hospital cardiac arrest. Advanced Resuscitation Training has been shown to improve survival to hospital discharge and survival with good neurological outcome following in-hospital cardiac arrest at its home institution. We sought to determine if Advanced Resuscitation Training implementation would improve patient outcomes and cardiopulmonary resuscitation quality at our institution. This was a prospective, before-after study of adult in-hospital cardiac arrest victims who had cardiopulmonary resuscitation performed. During phase 1, standard institution cardiopulmonary resuscitation training was provided. During phase 2, providers received the same quantity of training, but with emphasis on Advanced Resuscitation Training principles. Primary outcomes were return of spontaneous circulation, survival to hospital discharge, and neurologically favorable survival. Secondary outcomes were cardiopulmonary resuscitation quality parameters. A total of 156 adult in-hospital cardiac arrests occurred during the study period. Rates of return of spontaneous circulation improved from 58.1 to 86.3% with an adjusted odds ratios of 5.31 (95% CI: 2.23-14.35, P < 0.001). Survival to discharge increased from 26.7 to 41.2%, adjusted odds ratios 2.17 (95% CI: 1.02-4.67, P < 0.05). Survival with a good neurological outcome increased from 24.8 to 35.3%, but was not statistically significant. Target chest compression rate increased from 30.4% of patients in P1 to 65.6% in P2, adjusted odds ratios 4.27 (95% CI: 1.72-11.12, P = 0.002), and target depth increased from 23.2% in P1 to 46.9% in P2, adjusted odds ratios 2.92 (95% CI: 1.16-7.54, P = 0.024). After Advanced Resuscitation Training implementation, there were significant improvements in cardiopulmonary resuscitation quality and rates of return of spontaneous circulation and survival to discharge.

A Conceptual Framework to Reduce Inpatient Preventable Deaths

BackgroundEfforts to reduce preventable deaths in the in-hospital setting should target both cardiopulmonary arrest (CPA) prevention and optimal resuscitation. This requires consideration of a broad range of clinical issues and processes. A comprehensive, integrated system of care (SOC) that links data collection with a modular education program to reduce preventable deaths has not been defined. MethodsThis study was conducted in two urban university hospitals from 2005 to 2009. The Advanced Resuscitation Training (ART) program was implemented in 2007, incorporating hands-on resuscitative skills and in-hospital–specific training with an institutional resuscitation database. Linkage between the database and training modules occurs via the ART Matrix, which classifies all CPA events into the following etiologies: sepsis, hemorrhage, pulmonary embolus, heart failure, tachyarrhythmias, bradyarrhythmias, acute respiratory distress syndrome, non-intubated pulmonary disease, obstructive apnea, traumatic brain injury, ischemic brain injury, and intracranial mass lesions. This taxonomy was validated using descriptive statistics, before-and-after analysis evaluating CPA incidence, and multivariate logistic regression to predict CPA survival. ResultsA total of 336 inpatients suffered a cardiopulmonary arrest during the study period—187 in the pre-ART period and 149 in the post-ART period. The vast majority of CPA events were categorized using the ART Matrix with high inter-observer reliability. As anticipated, changes in CPA incidence and survival were observed for some Matrix categories but not others following ART implementation. In addition, multivariate logistic regression revealed strong independent associations between taxonomy classifications and outcome. ConclusionA novel SOC using a unique taxonomy for arrest classification appears to be effective at reducing inpatient CPA incidence and outcome.

A Continuous Quality Improvement Airway Program Results in Sustained Increases in Intubation Success

Introduction: Airway management is a critical skill for air medical providers, including the use of rapid sequence intubation (RSI) medications. Mediocre success rates and a high incidence of complications has challenged air medical providers to improve training and performance improvement efforts to improve clinical performance.Objectives: The aim of this research was to describe the experience with a novel, integrated advanced airway management program across a large air medical company and explore the impact of the program on improvement in RSI success.Methods: The Helicopter Advanced Resuscitation Training (HeART) program was implemented across 160 bases in 2015. The HeART program includes a novel conceptual framework based on thorough understanding of physiology, critical thinking using a novel algorithm, difficult airway predictive tools, training in the optimal use of specific airway techniques and devices, and integrated performance improvement efforts to address opportunities for improvement. The C-MAC video/direct laryngoscope and high-fidelity human patient simulation laboratories were implemented during the study period. Chi-square test for trend was used to evaluate for improvements in airway management and RSI success (overall intubation success, first-attempt success, first-attempt success without desaturation) over the 25-month study period following HeART implementation.Results: A total of 5,132 patients underwent RSI during the study period. Improvements in first-attempt intubation success (85% to 95%, p < 0.01) and first-attempt success without desaturation (84% to 94%, p < 0.01) were observed. Overall intubation success increased from 95% to 99% over the study period, but the trend was not statistically significant (p = 0.311).Conclusions: An integrated advanced airway management program was successful in improving RSI intubation performance in a large air medical company.

Electronic learning in advanced resuscitation training: The perspective of the candidate.

Studies have shown that blended approaches combining e-learning with face-to-face training reduces costs whilst maintaining similar learning outcomes. The preferences in learning approach for healthcare providers to this new style of learning have not been comprehensively studied. The aim of this study is to evaluate the acceptability of blended learning to advanced resuscitation training. Participants taking part in the traditional and blended electronic advanced life support (e-ALS) courses were invited to complete a written evaluation of the course. Participants' views were captured on a 6-point Likert scale and in free text written comments covering the content, delivery and organisation of the course. Proportional-odds cumulative logit models were used to compare quantitative responses. Thematic analysis was used to synthesise qualitative feedback. 2848 participants from 31 course centres took part in the study (2008-2010). Candidates consistently scored content delivered face-to-face over the same content delivered over the e-learning platform. Candidates valued practical hands on training which included simulation highly. Within the e-ALS group, a common theme was a feeling of "time pressure" and they "preferred the face-to-face teaching". However, others felt that e-ALS "suited their learning style", was "good for those recertifying", and allowed candidates to "use the learning materials at their own pace". The e-ALS course was well received by most, but not all participants. The majority felt the e-learning module was beneficial. There was universal agreement that the face-to-face training was invaluable. Individual learning styles of the candidates affected their reaction to the course materials.

A performance improvement-based resuscitation programme reduces arrest incidence and increases survival from in-hospital cardiac arrest

BackgroundTraditional resuscitation training models are inadequate to achieving and maintaining resuscitation competency. This analysis evaluates the effectiveness of a novel, performance improvement-based inpatient resuscitation programme. MethodsThis was a prospective, before-and-after study conducted in an urban, university-affiliated hospital system. All inpatient adult cardiac arrest victims without an active Do Not Attempt Resuscitation order from July 2005 to June 2012 were included. The advanced resuscitation training (ART) programme was implemented in Spring 2007 and included a unique treatment algorithm constructed around the capabilities of our providers and resuscitation equipment, a training programme with flexible format and content including early recognition concepts, and a comprehensive approach to performance improvement feeding directly back into training. Our inpatient resuscitation registry and electronic patient care record were used to quantify arrest rates and survival-to-hospital discharge before and after ART programme implementation. Multiple logistic regression analysis was used to adjust for age, gender, location of arrest, initial rhythm, and time of day. ResultsA total of 556 cardiac arrest victims were included (182 pre- and 374 post-ART). Arrest incidence decreased from 2.7 to 1.2 per 1000 patient discharges in non-ICU inpatient units, with no change in ICU arrest rate. An increase in survival-to-hospital discharge from 21 to 45% (p<0.01) was observed following ART programme implementation. Adjusted odds ratios for survival-to-discharge (OR 2.2, 95% CI 1.4–3.4) and good neurological outcomes (OR 3.0, 95% CI 1.7–5.3) reflected similar improvements. Arrest-related deaths decreased from 2.1 to 0.5 deaths per 1000 patient discharges in non-ICU areas and from 1.5 to 1.3 deaths per 1000 patient discharges in ICU areas, and overall hospital mortality decreased from 2.2% to 1.8%. ConclusionsImplementation of a novel, performance improvement-based inpatient resuscitation programme was associated with a decrease in the incidence of cardiac arrest and improved clinical outcomes.

Time matters – Realism in resuscitation training

BackgroundThe advanced life support guidelines recommend 2min of cardiopulmonary resuscitation (CPR) and minimal hands-off time to ensure sufficient cardiac and cerebral perfusion. We have observed doctors who shorten the CPR intervals during resuscitation attempts. During simulation-based resuscitation training, the recommended 2-min CPR cycles are often deliberately decreased in order to increase the number of scenarios. The aim of this study was to test if keeping 2-min CPR cycles during resuscitation training ensures better adherence to time during resuscitation in a simulated setting. MethodsThis study was designed as a randomised control trial. Fifty-four 4th-year medical students with no prior advanced resuscitation training participated in an extra-curricular one-day advanced life support course. Participants were either randomised to simulation-based training using real-time (120s) or shortened CPR cycles (30–45s instead of 120s) in the scenarios. Adherence to time was measured using the European Resuscitation Council's Cardiac Arrest Simulation Test (CASTest) in retention tests conducted one and 12 weeks after the course. ResultsThe real-time group adhered significantly better to the recommended 2-min CPR cycles (time-120s) (mean 13; standard derivation (SD) 8) than the shortened CPR cycle group (mean 45; SD 19) when tested (p<0.001.) ConclusionThis study indicates that time is an important part of fidelity. Variables critical for performance, like adherence to time in resuscitation, should therefore be kept realistic during training to optimise outcome.

High-Fidelity Simulation Training in Advanced Resuscitation for Pharmacy Residents

To assess the impact of high-fidelity patient simulation on pharmacy resident knowledge, confidence, and competency with advanced resuscitation algorithms and interventions. An overview of the institutional cardiopulmonary arrest algorithm and a review of pertinent medications and calculations were presented to postgraduate year 1 (PGY1) pharmacy residents, followed by participation in 3 simulated clinical scenarios using a high-fidelity mannequin. An improvement of pharmacy resident knowledge, confidence, and competency with advanced resuscitation skills was observed. In addition, pharmacy residents demonstrated high performance levels with skills requiring advanced competency and proactive interactions with the cardiac arrest team. Incorporating high-fidelity patient simulation into an advanced resuscitation training program can help pharmacy residents achieve competency through the active learning of practical skills.

Board 361 - Research Abstract Time Matters

Introduction/Background The advanced life support (ALS) guidelines recommend two minutes cardiopulmonary resuscitation (CPR) and a minimum of hands-off time to ensure the cardiac and cerebral perfusion.1,2 We have observed several doctors who rush CPR during actual and simulated resuscitation attempts without adherence to the recommended time intervals.3 Rushed CPR caused by frequent interruptions due to abbreviated intervals between rhythm control, endangers the perfusion as quality of CPR is impaired when frequent interruptions increases hand-off .4,5 During resuscitation training, to ensure as many simulations scenarios as possible, providing the learner with increased learning opportunity, the time is often compressed and the two minutes of CPR between rhythm control/defibrillation are shortened to 30-60 seconds where the instructor discontinues this part of the training to save time. This practice is presumably used relatively often and it has been observed on several occasions in several different settings by the authors and ALS instructors confirm it as a common practice. The aim of this study is to test the hypothesis that compressed time during simulation based resuscitation training is associated with a lack of adherence to time during resuscitation. Methods The study was designed as a randomized control trial study. Fifty-four 4th year medical students with no prior advanced resuscitation training participated in an extracurricular one day advanced life support course based on the European Resuscitation Council’s (ERC) ALS Guidelines 2010. Participants were randomized to receive either real-time simulation scenarios or compressed time simulation scenarios during the course. The control group was trained during simulation scenarios using compressed time, 30-45 seconds CPR between rhythm controls/defibrillation. The intervention group was trained during simulation scenarios using real-time, 120 seconds of CPR between rhythm controls/defibrillation. Participants were assessed in a post and retention test using the validated ERC Cardiac Arrest Simulation Test (CAS-Test), developed to the ERC ALS provider .6 For the individual assessment, three assistants aided the participant according to his or her instructions. Test scenario including a briefing and short post scenario debriefing with a total duration of 30 minutes per participant. Results Data was analyzed using commercial available statistical software Stata/IC 11.2 (StataCorp LP, Texas, USA). The ability to stay adherent to the recommended time and perform two minutes of CPR between rhythm controls was found to be significantly better (p<0.05) for the intervention group, compared to the control group in both post test and retention test. (Intervention group; Mean 115 sec ±SD 28 seconds, Control group; Mean 81 seconds ±SD 42 seconds). There were no statistically significant differences from post test to retention test within the individual groups. Conclusion Novices practice the way they are taught in training. Even with cognitive aids and timekeeping tools the control group presented with a skewed adherence to time. The intervention group had a strong and significantly better adherence to recommended time intervals. Despite the best intention and the attempt to give participants the best opportunity to learn by exposing them to as many simulated scenarios as possible by compressing time. It is likely that real-time should be used in order to enable the trainee to keep track of time during time-critical events in SBE or at least during advanced life support simulation training. Our Results suggest that time critical scenario training should be run real-time to ensure correct time management and adherence to time when practiced outside the training environment. In the immediate future, we believe that a shift to real-time scenarios will provide instructors with the tool or rather the time to improve the quality of training without impairment of adherence to time.

Abstract 297: Performance-Improvement Based Resuscitation Training Decreases Cardiopulmonary Arrests and Improves Survival

Background: Despite recent advances in cardiopulmonary arrest resuscitation, survival remains poor. Traditional training models have difficulty achieving and maintaining resuscitation competency. The UCSD Advanced Resuscitation Training (ART) Program, a performance-improvement based resuscitation program, has led to a sustained increase in survival to discharge after inpatient cardiac arrest from 21% to 45%. Objective: To evaluate the effectiveness of the ART program on survival after inpatient cardiac arrest and hospital mortality at the Veterans’ Affairs (VA) Hospital System in San Diego. Methods: This was a prospective, observational study conducted in an urban, university-affiliated VA. All inpatient cardiopulmonary arrest (CPA) victims without an active "Do Not Attempt Resuscitation" order from October 2006 to June 2012 were included. The ART program was implemented in Summer 2007 and included a unique treatment algorithm constructed around the capabilities of our providers and resuscitation equipment, a rapid response team, a training program with flexible format and content including early recognition concepts, and a comprehensive approach to performance improvement feeding directly back into training. Our inpatient resuscitation registry and electronic patient care records were used to quantify arrest rates and survival-to-hospital discharge yearly after ART program implementation. Results: A total of 476 CPAs were included (176 within the Intensive Care Unit (ICU) and Emergency Department (ED), and 300 outside of the ICU/ED). Arrest incidence decreased yearly from an initial rate of 10.3 to 2.7 CPA per 1,000 patient discharges in non-ICU inpatient units. Survival-to-discharge rates at the VA were comparable to those documented at UCSD (44% versus 45%, p=NS). Conclusions: Implementation of the ART program at the Veterans Affairs Medical Center resulted in a decrease in the incidence of CPA with high survival-to-discharge rates.

Abstract 248: Continuous Chest Compressions with Interposed Ventilations Are Associated with Improved Outcomes from Suspected Asphyxial Arrest

Background: A continuous chest compression (CCC) approach to CPR avoids pauses that decrease coronary perfusion pressure. However, the ability to provide adequate ventilation during CCC remains unclear. Cardiopulmonary arrest (CPA) victims with suspected asphyxia would be expected to be the most impacted by inadequate ventilation during CPR. Objective: To explore the impact of CCC on outcome from inpatients with suspected asphyxial CPA. Methods: This study was conducted in two urban university hospitals from 2005-09. The Advanced Resuscitation Training (ART) program was implemented in 2007. The ART program advocates CCC with interposed ventilations performed at a 10:1 ratio. Ventilations are initiated with the onset of compression recoil for both unprotected and protected airways. Data for all CPAs are entered into a resuscitation database. CPA events are categorized based on suspected etiology. Survival-to-discharge rates before and after implementation of the ART protocol were evaluated using chi-square analysis including test for trend. Ventilation rates were measured over the final 18 months of the study. Results: A total of 140 inpatients had suspected asphyxial CPA during the study period. Survival-to-discharge increased from 21.8% to 47.2% following implementation of the ART CCC protocol (p&lt;0.001). Average ventilation rates associated with CCC were 9.7 breaths/min. Conclusions: An inpatient CCC protocol with ventilations interposed at a 10:1 ratio was associated with marked improvements in outcome among patients with suspected asphyxial CPA. These data suggest that adequate ventilation can be achieved with synchronous delivery of breaths with the recoil phase of compressions. Controlled ventilation rates were also achieved.

Abstract 36: Etiology of In-Hospital Cardiopulmonary Arrest as a Predictor of Outcome

Background: Inpatient cardiopulmonary arrest (CPA) is poorly defined. However, understanding the factors contributing to incidence and outcome is critical in designing effecting CQI programs. Objective: To explore the effectiveness of an arrest taxonomy, using specific etiologies of inpatient CPA, to predict incidence and outcomes and direct CQI efforts. Methods: This study was conducted in two urban university hospitals from 2005-09. The Advanced Resuscitation Training (ART) program was implemented in 2007. Clinical and demographic data were abstracted from the institutional resuscitation database. Broad categories regarding arrest etiology [sepsis, hemorrhage, pulmonary embolus, VF/VT, vagal, neurologic, heart failure, intubated respiratory, and non-intubated respiratory] were incorporated into a multivariate logistic regression model using survival-to-hospital discharge as the primary outcome. In addition, chi-square analysis of incidence and graphical analysis of incidence and survival trends for specific etiologies before and after ART implementation were performed. Results: A total of 332 inpatients suffered CPA during the study period [pre-ART n=182, post-ART n=150]. Multivariate logistic regression revealed an independent association with outcome for each of the etiologies but not for other covariates. A decrease in the incidence and improvement in survival for certain arrest etiologies was observed following ART implementation. Conclusion: We observed important associations between arrest etiology and both incidence and outcome from inpatient CPA. This taxonomy may be helpful in guiding CQI efforts.

Abstract 269: A “Front-Loaded” Rapid Response Team Decreases Non-ICU Arrests and Overall Hospital Mortality

Background: In-hospital cardiopulmonary arrest (CPA) is characterized by progressive hypoxemia and hypotension leading to bradyasystole. Rapid response teams (RRTs) are designed to prevent non-ICU CPA through early detection and therapeutic intervention. However, existing evidence has not consistently demonstrated benefit to RRT programs. Objective: To explore the effectiveness of a “front-loaded” RRT program to decrease non-ICU CPA and overall hospital mortality. Methods: This study was conducted in two urban university hospitals from 2005 to 2011. In 2007, our hospitals implemented RRT as part of the Advanced Resuscitation Training (ART) program. Our RRT program is “front-loaded” in that charge nurses from each inpatient unit undergo training as RRT members, and all inpatient staff receive annual training in RRT concepts. To evaluate overall effectiveness of RRT, we compared the incidence of non-ICU CPA (per 1,000 patient discharges) before and after program implementation. The incidence of ICU CPA as well as overall hospital mortality were also reported. In addition, the overall number of RRT versus code blue activations for each individual inpatient unit were compared using linear regression. Finally, the annual change in RRT versus code blue activations for each inpatient unit were also compared. Results: A total of 546 CPAs were observed from 2005-11; a total of 725 RRT activations were observed from 2007-11. The incidence of non-ICU CPA decreased while the incidence of ICU CPA remained unchanged follow RRT program implementation. Overall hospital mortality also decreased over the study period (2.12% to 1.74%, p&lt;0.001). Inpatient units with a greater number of code blue activations also had more RRT activations (r=0.17, p=0.242). However, units with a year-over-year increase in RRT activations experienced a decrease in code blue activations, while units with a decrease in RRT activations experienced an increase in code blue activations (r=-0.68, p&lt;0.001). Conclusion: A front-loaded RRT program decreases the incidence of non-ICU CPA and overall hospital mortality.

Advanced Cardiac Resuscitation Evaluation (ACRE): A randomised single-blind controlled trial of peer-led vs. expert-led advanced resuscitation training

BackgroundAdvanced resuscitation skills training is an important and enjoyable part of medical training, but requires small group instruction to ensure active participation of all students. Increases in student numbers have made this increasingly difficult to achieve.MethodsA single-blind randomised controlled trial of peer-led vs. expert-led resuscitation training was performed using a group of sixth-year medical students as peer instructors. The expert instructors were a senior and a middle grade doctor, and a nurse who is an Advanced Life Support (ALS) Instructor.A power calculation showed that the trial would have a greater than 90% chance of rejecting the null hypothesis (that expert-led groups performed 20% better than peer-led groups) if that were the true situation. Secondary outcome measures were the proportion of High Pass grades in each groups and safety incidents.The peer instructors designed and delivered their own course material. To ensure safety, the peer-led groups used modified defibrillators that could deliver only low-energy shocks.Blinded assessment was conducted using an Objective Structured Clinical Examination (OSCE). The checklist items were based on International Liaison Committee on Resuscitation (ILCOR) guidelines using Ebel standard-setting methods that emphasised patient and staff safety and clinical effectiveness.The results were analysed using Exact methods, chi-squared and t-test.ResultsA total of 132 students were randomised: 58 into the expert-led group, 74 into the peer-led group. 57/58 (98%) of students from the expert-led group achieved a Pass compared to 72/74 (97%) from the peer-led group: Exact statistics confirmed that it was very unlikely (p = 0.0001) that the expert-led group was 20% better than the peer-led group.There were no safety incidents, and High Pass grades were achieved by 64 (49%) of students: 33/58 (57%) from the expert-led group, 31/74 (42%) from the peer-led group. Exact statistics showed that the difference of 15% meant that it was possible that the expert-led teaching was 20% better at generating students with High Passes.ConclusionsThe key elements of advanced cardiac resuscitation can be safely and effectively taught to medical students in small groups by peer-instructors who have undergone basic medical education training.

Quality of CPR during advanced resuscitation training

Previous studies have documented poor quality CPR during real life resuscitation attempts. This study investigated whether poor quality CPR during advanced life support training could be contributing to poor performance in clinical practice. Observational study of quality of CPR during advanced life support training courses before and after the implementation of the European Resuscitation Council Guidelines 2005 into the ALS course. The quality of chest compressions were downloaded from a manikin and direct observations of no-flow time; pre-shock pauses were recorded. 94 cardiac arrest simulations were studied (46 before implementation of Guidelines 2005 and 48 after). Delays in starting CPR, inadequate compression depth, prolonged interruptions of chest compressions and excessive pre-shock pauses were identified. The introduction of Guidelines 2005 resulted in improvements in the number of compressions given per minute and a reduction in no-flow time and duration of pre-shock pauses, but overall the quality of CPR performed during the ALS course remained poor. There was little evidence of performance improving over successive simulations as the course progressed. The implementation of Guidelines 2005 into the ALS course appear to have improved the process of CPR by reducing no-flow time during simulated CPR. However, the quality of CPR during ALS training remains sub-optimal. Delays in starting CPR, inadequate compression depth, excessive interruptions in chest compressions and prolonged pre-shock pauses mirror observations from clinical practice. Strategies to improve CPR performance during ALS training should be explored and potentially may result in improvements in clinical practice.

Cardio-pulmonary resuscitation training, knowledge and attitudes of newly-qualified doctors in New Zealand in 2003

To assess the resuscitation knowledge and confidence of newly-qualified doctors in New Zealand (NZ) in 2003. Anonymous questionnaires were distributed to all newly-qualified doctors in NZ (n=279). Two hundred and thirty-three respondents from hospitals throughout NZ (84% response rate). Resuscitation training received during medical school and use of recommended text (Level 7 of NZ resuscitation manual), confidence in resuscitation skills and core knowledge of basic and advanced resuscitation. 98.3% of doctors received advanced resuscitation training during their final year of medical school, of these 64.6% had received training in the previous 6 months. The mean knowledge score was 56.6% and 45% of doctors made 'fatal errors'. Eighty-four percentage of doctors had read the Level 7 manual and 72.6% found it very or extremely useful. Those who had read the manual had higher scores and were less likely to make a 'fatal error'. Having attended a cardiac arrest and having received training within the last 6 months improved doctor confidence in resuscitation. The resuscitation knowledge and confidence of newly-qualified doctors in NZ are sub-optimal, with some doctors displaying dangerous deficiencies. Our results suggest mandatory attainment of an advanced resuscitation certificate, six-monthly practical resuscitation sessions and increased exposure to real resuscitation situations should be implemented to improve undergraduate resuscitation training.

Part 6: Advanced Cardiovascular Life Support

Part 6: Advanced Cardiovascular Life Support