Cardiopulmonary Resuscitation Attempts Research Articles

Performance of the i-gel™ during pre-hospital cardiopulmonary resuscitation

BackgroundCurrent cardiopulmonary resuscitation (CPR) guidelines recommend airway management and ventilation whilst minimising interruptions to chest compressions. We have assessed i-gel™ use during CPR. MethodsIn an observational study of i-gel™ use during CPR we assessed the ease of i-gel™ insertion, adequacy of ventilation, the presence of a leak during ventilation, and whether ventilation was possible without interrupting chest compressions. ResultsWe analysed i-gel™ insertion by paramedics (n=63) and emergency physicians (n=7) in 70 pre-hospital CPR attempts. There was a 90% first attempt insertion success rate, 7% on the second attempt, and 3% on the third attempt. Insertion was reported as easy in 80% (n=56), moderately difficult in 16% (n=11), and difficult in 4% (n=3). Providers reported no leak on ventilation in 80% (n=56), a moderate leak in 17% (n=12), and a major leak with no chest rise in 3% (n=2). There was a significant association between ease of insertion and the quality of the seal (r=0.99, p=0.02). The i-gel™ enabled continuous chest compressions without pauses for ventilation in 74% (n=52) of CPR attempts. There was no difference in the incidence of leaks on ventilation between patients having continuous chest compressions and patients who had pauses in chest compressions for ventilation (83% versus 72%, p=0.33, 95% CI [−0.1282, 0.4037]). Ventilation during CPR was adequate during 96% of all CPR attempts. ConclusionsThe i-gel™ is an easy supraglottic airway device to insert and enables adequate ventilation during CPR.

Improving end-of-life care in nursing homes: Implementation and evaluation of an intervention to sustain quality of care

Background: Internationally, policy calls for care homes to provide reliably good end-of-life care. We undertook a 20-month project to sustain palliative care improvements achieved by a previous intervention. Aim: To sustain a high standard of palliative care in seven UK nursing care homes using a lower level of support than employed during the original project and to evaluate the effectiveness of this intervention. Design: Two palliative care nurse specialists each spent one day per week providing support and training to seven care homes in Scotland, United Kingdom; after death audit data were collected each month and analysed. Results: During the sustainability project, 132 residents died. In comparison with the initial intervention, there were increases in (a) the proportion of deceased residents with an anticipatory care plan in place (b) the proportion of those with Do Not Attempt Cardiopulmonary Resuscitation documentation in place and (c) the proportion of those who were on the Liverpool Care Pathway when they died. Furthermore, there was a reduction in inappropriate hospital deaths of frail and elderly residents with dementia. However, overall hospital deaths increased. Conclusions: A lower level of nursing support managed to sustain and build on the initial outcomes. However, despite increased adoption of key end-of-life care tools, hospital deaths were higher during the sustainability project. While good support from palliative care nurse specialists and GPs can help ensure that key processes remain in place, stable management and key champions are vital to ensure that a palliative care approach becomes embedded within the culture of the care home.

Barriers to involving older people in their resuscitation decisions: the primary-secondary care mismatch highlights the potential role of general practitioners

'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) orders are made frequently for older people in hospital. Sensitive anticipatory discussion is encouraged where possible, but usually this does not happen, despite the evidence suggesting that many older patients would like to be involved in such decisions. Current clinical practice in both primary care and secondary care and perceived barriers to patient involvement in resuscitation decisions was assessed using a questionnaire in Medicine for the Elderly physicians in two hospitals, and General Practitioners of teaching practices in Norfolk. Response rate was 51% (n = 24/47). Hospital-based clinicians made DNACPR decisions more frequently, but discussed decisions with patients in less than 25% of cases. By contrast, GPs thought that patient involvement was more important and felt that they had a better understanding of the patient's wishes due to the long-term relationship they shared. Mental capacity was seen as the biggest barrier to patient involvement by both groups. Other barriers included lack of understanding, communication difficulties and practical concerns. Further support and training could help clinicians improve their resuscitation decision-making practice. Advanced discussion in Primary Care with older people before they lose capacity may have a role in increasing their involvement in resuscitation decision making.

Emergency care staff experiences of lay presence during adult cardiopulmonary resuscitation: a phenomenological study

BackgroundPublic support in favour of family presence during an adult cardiopulmonary resuscitation (CPR) attempt is a contentious issue among providers of emergency care. Researchers have mostly relied on attitudinal surveys...

Experience of Belgrade’s Emergency Medical Service in the implementation of cardiopulmonary resuscitation guidelines issued in 2010

Introduction. Implementation of cardiopulmonary resuscitation (CPR) is defined by the unified 2010 Guidelines for CPR. Objective. This paper presents the experience of Belgrade’s Emergency Medical Services (EMS) in the implementation of out-of-hospital (OH) CPR according to the new, 2010 Guidelines.Methods. A retrospective study design was used. We recorded OH CPR and analyzed four variables: patient gender and age, arrest location, bystander witnessed arrest, and arrest rhythm (shockable – group I, non-shockable – group II). The study also looked at implementation and follow-up of CPR, therapy, CPR duration, EMS reaction time, and patient outcome (Return of Spontaneous Circulation [ROSC] or death). Results. Of 794 OH CPR attempts, 136 (17%) patients with field ROSC were transported to hospital admission (HA) (22% group I, 78% group II). ROSC at HA was sustained in 64 (47%), and unsustained in 72 (53%) patients. Among the patients with ROSC on HA, 47% had spontaneous breathing and 5% fully regained consciousness. The ROSC rate was higher after arrest occurring at home (P<0.001). No statistical significance between the groups regarding the following analyzed variables was found: patient gender, age, onset time (day or night shift), bystander witnessed arrest, ROSC, breathing and consciousness at HA. In all patients, intravenous (IV) access was established. Atropine was administered in 28 (21%) group II patients. Adrenaline was administered in 71% of patients and withheld in 29% of patients due to hospital closeness or sustained ROSC. By HA, 46% were successfully intubated. The average response time in group I was 8.1±4.0 minutes, in group II 6.8 ± 4.4 minutes. A highly significant association (p<0.01) was found between CPR duration and ROSC at HA (26.23 min – ROSC vs. 14.46 min – no ROSC).Conclusion. Study results indicate the significance of the new Guidelines for CPR in the everyday practice of Belgrade’s EMS teams. Continual training increases the quality of administered CPR measures and the rate of patients with ROSC at HA. New studies would contribute to the disclosure of weak links in the survival chain after OH CPR in Belgrade.

Do Not Attempt Cardiopulmonary Resuscitation orders in acute medical settings: a qualitative study

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders have been shown to be independently associated with patients receiving fewer treatments, reduced admission to intensive care and worse outcomes even after accounting for known confounders. The mechanisms by which they influence practice have not previously been studied. To present a rich qualitative description of the use of the DNACPR form in a hospital ward setting and explore what influence it has on the everyday care of patients. Multi-source qualitative study, primarily using direct observation and semi-structured interviews based on two acute wards in a typical middle-sized National Health Service hospital in UK. The study identified a range of ways in which DNACPR orders influence ward practice, beyond dictating whether or not cardiopulmonary resuscitation should be attempted. Five key themes encapsulate the range of potential impacts emerging from the data: the specific design and primacy of the form, matters relating to clinical decision making, staff reflections on how the form can affect care, staff concern over 'inappropriate' resuscitation, and discussions with patients/relatives about DNACPR decisions. Overall, it was found that while the DNACPR form is recognized as serving a useful purpose, its influence negatively permeated many aspects of clinical practice. DNACPR orders can act as unofficial 'stop' signs and can often signify the inappropriate end to clinical decision making and proactive care. Many clinicians were uncomfortable discussing DNACPR orders with patients and families. These findings help understand why patients with DNACPR orders have worse outcomes, as such they may inform improvements in resuscitation policies.

Abstract 298: Efficacy of Bag-Mask Ventilation for Ventricular Fibrillation Sudden Cardiac Arrest

Background: If bag-mask ventilation is adequate, an advanced airway is not urgently required. Although rescuers may defer insertion of an advanced airway until the patient fails to respond to initial cardiopulmonary resuscitation (CPR) and defibrillation attempts or has return of spontaneous circulation (ROSC), its effects and optimal timing remain unclear. Methods: An observational study was performed in 670,313 patients who had out-of-hospital cardiac arrest (OHCA) in Japan and received CPR between January 1, 2005 and December 31, 2010. Of these patients, 9,720 in whom age was from 18 to 74 years, OHCA was cardiogenic, the scene of OHCA was witnessed, bystander CPR was performed, and initial rhythm was ventricular fibrillation (VF) were studied. The subjects were divided into two groups according to the method used for airway management by emergency medical service (EMS) personnel: 5,358 who used a bag-valve mask (bag-mask ventilation group: BMV group) and 4,362 who used an advanced airway including a supraglottic airway device and endotracheal tube (advanced airway management group: AAM group). The rates of ROSC from the initiation of EMS-CPR to arrival at the hospital were compared. Next, subjects who did not have ROSC within 45 minutes before arrival at the hospital were divided into two groups, the pre-hospital non-ROSC BMV group (N=3,092) and the pre-hospital non-ROSC AAM group (N=3,291), and neurologic outcomes at 30 days were compared. A favorable outcome was defined as a Cerebral Performance Category (CPC) of 1 or 2. Results: The rate of ROSC from the initiation of EMS-CPR to arrival at the hospital was higher (41% vs. 21%, p&lt;0.01) in the BMV group than in the AAM group. The rate of favorable outcomes was higher (8% vs. 3%, p&lt;0.01) in the pre-hospital non-ROSC BMV group than in the pre-hospital non-ROSC AAM group. In particular, the rate of favorable outcomes was higher in the pre-hospital non-ROSC BMV group than in the pre-hospital non-ROSC AAM group during the first 20 minutes after the initiation of EMS-CPR. Conclusions: In patients with VF sudden cardiac arrest, the use of a bag-valve mask for airway management increases the rates of ROSC and favorable outcomes, particularly during the initial period from EMS-CPR to arrival at the hospital.

Commotio Cordis, Therapeutic Hypothermia, and Evacuation from a United States Military Base in Iraq

BackgroundTherapeutic hypothermia (TH) has been demonstrated to improve clinical outcomes after out-of-hospital ventricular fibrillation (VF) cardiac arrest. It remains unclear if TH can be safely and effectively used in the setting of traumatic arrest. Furthermore, the use of TH methods in the pre-hospital and transport environments remain poorly established and a domain of active investigation. ObjectivesTo describe a case of successful TH utilization after blunt trauma with commotio cordis and pulmonary contusion, and to describe the continuation of TH during international fixed-wing aeromedical transport. Case ReportA 33-year-old active duty soldier suffered blunt chest trauma and immediate VF arrest. He was successfully resuscitated with cardiopulmonary resuscitation and defibrillation attempts. Given his ensuing comatose post-arrest state, he was therapeutically cooled and subsequently evacuated from Iraq to Germany, with cooling maintenance established in flight without the availability of training or commercial cooling equipment. The patient exhibited an eventual excellent neurologic recovery. To utilize TH for this patient, military physicians with limited local resources employed a telemedical approach to obtain a hypothermia protocol to develop a successful treatment plan. ConclusionsThe patient's successful resuscitation suggests that care should not be withheld for blunt trauma patients without vital signs in the field if VF is present, until the differential diagnosis of commotio cordis has been considered.

In-hospital use of an automatic mechanical chest compression device to continue prolonged out-of-hospital cardiopulmonary resuscitationStatus: PendingCategory: Mechanical Devices

Purpose of the study: The usage of an automatic chest compression device (LUCAS™-device) during resuscitation is an alternative to manual chest compression.1,2 Prolonged out-of-hospital (OOH) cardiopulmonary resuscitation (CPR) and transport under ongoing CPR mostly results in unfavourable outcome. The primary objective was to analyze the benefit of continuation of CPR attempts after hospital admission by using the device.

Expert review of cardiopulmonary resuscitation (CPR) in hospital

The recent NCEPOD report (2012a) on patients undergoing CPR following cardiorespiratory arrest in hospital raises a number of important care quality and patient safety issues related to CPR. Some examples include the taking of an adequate patient medical history during the initial admission process, healthcarer recognition of patients’ deteriorating condition, adequacy of patient monitoring and proper documentation. Fundamentally important legal and ethical issues are also raised, such as patients’ informed consent to CPR, the need to agree the ‘ceilings of treatment’ with the patient, the poor patient survival rate after CPR in hospital, and the need to avoid futile CPR attempts during the patient’s dying process. Do nurses and doctors think that they have a duty to do everything that they can to prolong the process of dying? There is a need for nurses, doctors and managers to accept that death does not always represent a failure of health care, and that enabling people to die as well as possible is one of the core functions of the NHS.

A video decision support tool for CPR in advanced cancer: A randomized controlled trial.

9004 Background: End-of-life decision-making is important to patients, including whether or not to attempt cardiopulmonary resuscitation (CPR). Doctors often rely solely on verbal descriptions to communicate information regarding CPR. Video decision support tools have the potential to improve patients’ understanding of CPR by providing visual images of what this intervention entails. The objective of this study was to examine the effect of a CPR video among patients with advanced cancer on their preferences and knowledge of CPR. Methods: A randomized controlled trial of 150 subjects with diverse advanced cancers (&lt; 1-year prognosis) recruited from 4 cancer centers in the United States. Subjects were randomized to either a verbal narrative describing CPR, or to a video with verbal narrative. The video depicts CPR and reviews the success rate in advanced cancer. Study endpoints were subjects’ CPR preferences, knowledge of CPR (knowledge scores ranged from 0-4, higher score indicating more knowledge), and perceived value of the video. Chi-square tests were used to compare the distributions of categorical outcomes and two-sample t-tests were used to compare the means between the two groups. Results: A total of 150 subjects were randomized to a verbal narrative (n=80) or video with verbal narrative (n=70). Mean age was 62, 49% were women, 47% White, 34% Black, and 47% had lung or colon cancer. Among subjects receiving the verbal narrative, 38 (47.5%) preferred to have CPR attempted; 41 (51.2%) chose not to have CPR; and 1 (1.3%) was uncertain. In the video group, 14 (20%) preferred to have CPR attempted; 55 (78.6%) chose not to have CPR; and 1 (1.4%) was uncertain (P&lt;0.001). The mean knowledge score was higher in the video group than in the verbal group (3.3 vs. 2.6 respectively; P&lt;0.001). Of the subjects who viewed the video, 94.1% stated they were comfortable watching the video, 97.1% found the video helpful, and 100% would recommend the video. Conclusions: Compared to subjects who only heard a verbal description, subjects with advanced cancer who viewed a CPR video were more likely to prefer not having CPR, and were more knowledgeable about CPR. The majority of subjects found the video helpful, comfortable to view, and would recommend it to others.

Deciding right – the UKs first regional integration of advance care decisions

The need for clear decisions and protocols during emergencies has to be balanced against the need to make decisions that avoid unnecessary or distressing treatment. A regional initiative has the...

NHS Scotland DNACPR and CYPADM integrated policies – development of quality measures

BackgroundIn May 2010 National Health Service (NHS) Scotland published Europe's first fully integrated national policy for Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision making and communication in adults. The Scottish...

Prediction protocol for neurological outcome for survivors of out-of-hospital cardiac arrest treated with targeted temperature management

AimTo identify patients who can obtain the full benefit from targeted temperature management (TTM) after out-of-hospital cardiac arrest. MethodsWe performed a retrospective observational study of comatose patients treated with TTM after an out-of-hospital cardiac arrest from January 2006 to February 2011. Neurological outcome was evaluated with the Glasgow-Pittsburgh Cerebral Performance category (CPC) at discharge and predictors were determined. ResultsOf 66 patients studied, 40 (60.6%) survived to neurologically intact discharge (CPC 1 or 2). According to multivariate analysis, predictors of good neurological outcome included arrest-to-first cardiopulmonary resuscitation attempt interval ≤5min, ventricular fibrillation or ventricular tachycardia in the first monitored rhythm, absence of re-arrest before leaving the emergency department, arrest-to-return of spontaneous circulation interval ≤30min and recovery of pupillary light reflex, which were identifiable in the emergency department. Based on this analysis, we developed a seven-point score (5-R score). If the score was ≥5, it predicted good neurological outcome with a sensitivity of 82.5% (95% confidence interval [CI], 67.2–92.7%) and specificity of 92.3% (95% CI, 74.9–99.1%). The negative predictive value of a score ≥4 was 100% (95% CI, 81.5–100%). Our prediction model was validated internally by a bootstrapping technique. ConclusionsThe prediction protocol using the 5-R score was associated with good neurological outcome of patients treated with TTM. Therefore, it could be helpful in clinical decision making on whether to initiate cooling.

Choice of hospital after out-of-hospital cardiac arrest - a decision with far-reaching consequences: a study in a large German city

IntroductionBetween 1 and 31% of patients suffering out-of-hospital cardiac arrest (OHCA) survive to discharge from hospital. International studies have shown that the level of care provided by the admitting hospital determines survival for patients suffering from OHCA. These data may only be partially transferable to the German medical system where responders are in-field emergency medical physicians. The present study determines the influence of the emergency physician's choice of admitting hospital on patient outcome after OHCA in a large urban setting.MethodsAll data for patients collected in the German Resuscitation Registry for the city of Dortmund during 2007 and 2008 were analyzed. Patients under 18 years of age, with traumatic mechanism, and with incomplete charts were excluded. Admitting hospitals were divided into two groups: those without the capability for percutaneous coronary intervention (PCI), and those with PCI capability. Data were analyzed by multivariate statistics, taking into account the effects of mild therapeutic hypothermia treatment and PCI capability of the admitting hospital with respect to the neurological status upon hospital discharge.ResultsBetween 2007 and 2008 a total of 1,109 cardiopulmonary resuscitation attempts were registered for the city of Dortmund, of which 889 could be included in our study. Return of spontaneous circulation was achieved in 360 of 889 patients (40.5%). In total, 282 of 889 patients displayed return of spontaneous circulation during transport to the hospital (31.7%); 152 were transported with ongoing cardiopulmonary resuscitation (17.1%). Of the total 434 patients admitted to hospital, 264 were admitted to hospitals without PCI capability and 170 to hospitals with PCI capability. Multivariate analysis demonstrated a significant influence on patient discharge with good neurological status for those admitted to PCI hospitals (odds ratio 3.14 (95% confidence interval 1.51 to 6.56)), independent of receiving mild therapeutic hypothermia and/or PCI. Compared with patients admitted to hospitals without PCI capability, significantly more patients in PCI hospitals were discharged alive (41% vs. 13%, P < 0.001) and remained alive 1 year after the event (28% vs. 6%, P < 0.001).ConclusionsThe choice of admitting hospital for patients suffering OHCA significantly influences treatment and outcome. This influence is independent of PCI performance and of mild therapeutic hypothermia. Further analysis is required to determine the possible parameters determining patient outcome.

Abstract 17780: Efficacy of Bag-Mask Ventilation for Ventricular Fibrillation Sudden Cardiac Arrest

Background: If bag-mask ventilation is adequate, an advanced airway is not urgently required. Although rescuers may defer insertion of an advanced airway until the patient fails to respond to initial cardiopulmonary resuscitation (CPR) and defibrillation attempts or has return of spontaneous circulation (ROSC), its effects and optimal timing remain unclear. Methods: An observational study was performed in 547,218 patients who had out-of-hospital cardiac arrest (OHCA) in Japan and received CPR between January 1, 2005 and December 31, 2009. Of these patients, 15,675 in whom age was from 18 to 74 years, OHCA was cardiogenic, the scene of OHCA was witnessed, bystander CPR was performed, and initial rhythm was ventricular fibrillation (VF) were studied. The subjects were divided into two groups according to the method used for airway management by emergency medical service (EMS) personnel: 8,101 who used a bag-valve mask (bag-mask ventilation group: BMV group) and 7,574 who used an advanced airway including a supraglottic airway device and endotracheal tube (advanced airway group: AA group). The rates of ROSC from the initiation of EMS CPR to arrival at the hospital were compared. Next, subjects who did not have ROSC within 45 minutes before arrival at the hospital were divided into two groups, the pre-hospital non-ROSC BMV group (N=5,127) and the pre-hospital non-ROSC AA group (N=5,867), and neurologic outcomes at 30 days were compared. A favorable outcome was defined as a Cerebral Performance Category (CPC) of 1 or 2. Results: The rate of ROSC from the initiation of EMS CPR to arrival at the hospital was higher (35.5% vs. 19.8%, p&lt;0.01) in the BMV group than in the AA group. The rate of favorable outcomes was higher (5.7% vs. 2.9%, p&lt;0.01) in the pre-hospital non-ROSC BMV group than in the pre-hospital non-ROSC AA group. In particular, the rate of favorable outcomes was higher in the pre-hospital non-ROSC BMV group than in the pre-hospital non-ROSC AA group during the first 25 minutes after the initiation of EMS CPR. Conclusions: In patients with ventricular fibrillation sudden cardiac arrest, the use of a bag-valve mask for airway management increases the rates of ROSC and favorable outcomes, particularly during the initial period from EMS CPR to arrival at the hospital.

Abstract 65: Defining Lay Bystanders' Knowledge, Attitudes and Beliefs Toward Cardiopulmonary Resuscitation Training and Performance

Background: Since less than 30% of lay witnesses to cardiac arrest attempt cardiopulmonary resuscitation (CPR), understanding the public's perception of CPR training and performance is essential to inform future CPR training methods. Little is known regarding layperson perspectives on CPR in context of the 2010 resuscitation guidelines and the development of hands-only CPR. Objectives: We hypothesized that bystanders would feel more confident performing CPR when made aware of the new guidelines support for hands-only CPR. Methods: Subjects participated in an hour-long semi-structured qualitative interview. The interview script covered general questions designed to understand subject's perspectives on CPR training and performance. Following transcription, all responses were coded and processed using NVivo 9 qualitative analysis software. Results: Interviews were completed by 19 subjects, of whom 11% were untrained, 47% had completed a training course within the past 5 years and 42% had completed a course in the past 5+ years. Less than 49% of the subjects could describe when to perform CPR, and those who described using CPR incorrectly confused the lifesaving skill with first aid (64%) or clearing of the airway (27%). Subjects described incomplete training, lack of hands-on practice time (38%) and difficulty with skill retention (21%) as top themes surrounding their previous CPR training. Lack of confidence in CPR skills was a commonly reported theme among 79% of interviewees, despite 41% of these respondents having been trained within 5 years. When asked about hands-only CPR, 74% of the subjects had not heard of the new technique and 68% were unaware of the updated 2010 CPR guidelines. When briefly educated about the 2010 guidelines, 89% felt more confident with performing CPR if they had the option of employing “hands-only” CPR (p&lt;0.01). Conclusions: CPR trained individuals lacked confidence and retention of CPR knowledge, and were not aware of hands-only CPR and the 2010 resuscitation guidelines update. When informed about the option for hands-only CPR, individual's self-reported confidence increased significantly. This has implications for future public messaging surrounding layperson CPR and the need to promote hands-only CPR more broadly.

Cardiopulmonary Resuscitation Outcome of Out-of-hospital Cardiac Arrest in Low-volume versus High-volume Emergency Departments: An Observation Study and Propensity Score Matching Analysis

This retrospective cohort study investigated survival to discharge for out-of-hospital cardiac arrest (OHCA) patients' at low-volume cardiopulmonary resuscitation (CPR) facilities (< 68 CPR cases per year) vs. high-volume CPR facilities (> 69 CPR cases per year). Data were collected from ambulance run sheets during a 2-year period for all patients that had OHCA in Korea. More than 20,000 patients with OHCA were included. Patients were excluded if they were transferred to a facility other than an emergency department, if the cause of OHCA was trauma related, or if there was no CPR attempt by emergency medical personal in the out-of-hospital setting.

CPR in the nursing home: fool’s errand or looming dilemma?

The indications for CPR (cardiopulmonary resuscitation) have expanded greatly since the technique was introduced and theoretically it can be attempted on all prior to death. Policy initiatives (such as the British Medical Association/Royal College of Nursing guidelines) have attempted to provide a clinical rationale for the withholding of inappropriate CPR. Traditionally a care home was felt to be an inappropriate environment to attempt CPR but increased use of advance directives may bring the issue to the fore in this setting. We elicited the views of managers of care homes regarding resuscitation strategies in hypothetical situations and in actual practice. A purpose designed questionnaire in two parts was compiled, gathering factual information and employing a Likert scale to gauge opinion about this issue. The survey was conducted among 187 continuing care homes in South London the subjects being the care managers of the homes surveyed. Responses were obtained from 86 care homes. Care managers would resuscitate 66% of cases of witnessed cardiac arrest but few efforts were reported. Policies in assigning 'Do not resuscitate' orders were referred to by only 9% of homes but 80% of facilities would welcome them, yet 50% would exclude the patient from this discussion. Clear policy guidelines are required for continuing care homes, and advance statements about CPR as part of residents care plans could reduce inappropriate resuscitative efforts and hospital transfers.

The Effectiveness of Ultrabrief and Brief Educational Videos for Training Lay Responders in Hands-Only Cardiopulmonary Resuscitation

Bystander cardiopulmonary resuscitation (CPR) improves survival from out-of-hospital cardiac arrest (OHCA) but often is not performed. We hypothesized that subjects viewing very short Hands-Only CPR videos will (1) be more likely to attempt CPR in a simulated OHCA scenario and (2) demonstrate better CPR skills than untrained individuals. This study is a prospective trial of 336 adults without recent CPR training randomized into 4 groups: (1) control (no training) (n=51); (2) 60-second video training (n=95); (3) 5-minute video training (n=99); and (4) 8-minute video training, including manikin practice (n=91). All subjects were tested for their ability to perform CPR during an adult OHCA scenario using a CPR-sensing manikin and Laerdal PC SkillReporting software. One half of the trained subjects were randomly assigned to testing immediately and the other half after a 2-month delay. Twelve (23.5%) controls did not even attempt CPR, which was true of only 2 subjects (0.7%; P=0.01) from any of the experimental groups. All experimental groups had significantly higher average compression rates (closer to the recommended 100/min) than the control group (P<0.001), and all experimental groups had significantly greater average compression depth (>38 mm) than the control group (P<0.0001). Laypersons exposed to very short Hands-Only CPR videos are more likely to attempt CPR and show superior CPR skills than untrained laypersons. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01191736.