Major incidents: training for on site medical personnel.

OBJECTIVE: To assess the present levels of training for the medical incident officer (MIO) and the mobile medical team leader (MMTL) throughout the UK. METHOD: Postal questionnaire to consultants in charge of accident and emergency (A&E) departments seeing more than 30,000 patients a year. Information regarding MIO staffing and training and MMTL training and provision requested. RESULTS: A&E provides the majority of both MIOs and MMTLs in the event of a major incident. Virtually all MIOs are consultants or general practitioners. However, 63% of MMTLs are from hospital training grade staff. One third of hospitals required their designated MIO to have undertaken a Major Incident Medical Management and Support course and a quarter had no training requirement at all. Two thirds of MMTLs were expected to have completed an Advanced Trauma Life Support course, but in 21% there was no minimum training requirement. Training exercises are infrequent, and hence the exposure of any one individual to exercises will be minimal. CONCLUSION: There has been some improvement in major incident training and planning since 1992, but much remains to be done to improve the national situation to an acceptable standard.     

Should relatives be allowed in the resuscitation room?

OBJECTIVE: To assess doctors' and nurses' views on the presence of relatives in the resuscitation room during cardiac arrest or major trauma. DESIGN: Questionnaires were sent to accident and emergency (A&E) nurses and doctors of all disciplines in a London teaching hospital. Recipients were asked if they would favour the presence of selected relatives in the resuscitation room and to give comments. RESULTS: 103 questionnaires were distributed and 81 returned, a response rate of 78.6%; 33% were senior house officers, 29% consultants, 16% senior registrars/registrars, 12% A&E nurses, and 10% house officers. Of the respondents, 63% were not in favour of relatives being present, and 37% were in favour. The likelihood of being in favour of allowing relatives to be present was high among A&E nurses; among doctors it increased with rising seniority. Most respondents felt that more resuscitation training would be necessary, in addition to counselling for staff and relatives. CONCLUSIONS: Staff with the least experience in dealing with resuscitations and distressed relatives were likely to be opposed to relatives being present in the resuscitation room. As there is evidence that the bereavement process is eased if a partner/relative witnesses the resuscitation, relatives should be offered the opportunity to witness resuscitation if staff training is geared towards the presence of relatives. ALS/ATLS training for all hospital doctors and nurses should include the management of distressed relatives observing a resuscitation.     

Use of advanced life support skills

BACKGROUND: The Advanced Life Support (ALS) Provider Course trains healthcare professionals in a standardised approach to the management of a cardiac arrest. In the setting of limited resources for healthcare training, it is important that courses are fit for purpose in addressing the needs of both the individual and healthcare system. This study investigated the use of ALS skills in clinical practice after training on an ALS course amongst members of the cardiac arrest team compared to first responders. METHODS: Questionnaires measuring skill use after an ALS course were distributed to 130 doctors and nurses. RESULTS: 91 replies were returned. Basic life support, basic airway management, manual defibrillation, rhythm recognition, drug administration, team leadership, peri- and post-arrest management and resuscitation in special circumstances were used significantly more often by cardiac arrest team members than first responders. There was no difference in skill use between medically and nursing qualified first responders or arrest team members. CONCLUSION: We believe that the ALS course is more appropriately targeted to members of a cardiac arrest team. In our opinion the recently launched Immediate Life Support course, in parallel with training in the recognition and intervention in the early stages of critical illness, are more appropriate for the occasional or first responder to a cardiac arrest.     

The European Resuscitation Council's paediatric life support course 'Advanced Paediatric Life Support'

The poor outcome for resuscitation from cardiopulmonary arrest in childhood is widely recognised. The European Resuscitation Council has adopted the Advanced Paediatric Life Support course (originating in the UK and now available in a number of countries) as its course for providers caring for children. This paper outlines the course content and explains its remit, which is to reduce avoidable deaths in childhood by not only resuscitation from cardiac arrest but, more effectively, by recognising and treating in a timely and effective fashion life-threatening illness and injury in infants and children. Two related courses Paediatric Life Support, a less intense course for less advanced providers, and Pre-Hospital Paediatric Life Support for immediate care providers are also described.     

Conjunctival oxygen monitoring during cardiopulmonary resuscitation.

The conjunctival oxygen tension (CjO2) sensor is a non-invasive, continuous index of oxygen delivery in the haemodynamically unstable patient. Human and animal studies have indicated that CjO2 reflects cerebral blood flow and oxygenation. Simple insertion, rapid stabilization and reaction time less than 60 s allow use in the initial stages of cardiopulmonary resuscitation (CPR) where invasive monitoring is often impracticable. CjO2 was monitored to assess cerebral oxygenation during CPR of 15 patients in cardiac arrest in the accident and emergency department (A&E). Patients who arrested out of hospital with delay to advanced cardiac life support and died had CjO2 less than 20 mmHg (normal CjO2 50-60 mmHg) on arrival in A&E. CPR with closed chest cardiac massage (closed CPR) produced no improvement in CjO2. Patients who arrested in ventricular fibrillation (VF) in A&E, and survived with no neurological deficit had CjO2 greater than 20 mmHg during CPR. However, further episodes of VF produced an immediate fall in CjO2 which continued, despite closed CPR, until restoration of spontaneous cardiac output (RSCO) determined by a palpable carotid pulse. In survivors with delay from arrest to CPR the rise in CjO2 with RSCO did not occur for up to 10 min. This study suggests that closed CPR has no value in maintaining or improving cerebral oxygenation during cardiac arrest. Further studies are required to determine the precise relationship of CjO2 to cerebral blood flow and oxygenation during CPR using open and closed techniques of cardiac massage. Open chest cardiac massage (open CPR) has been shown to produce near normal cerebral perfusion and if patients are to survive prolonged resuscitation neurologically intact guidelines for open CPR must be reviewed.     

Paramedics, technicians, and survival from out of hospital cardiac arrest.

OBJECTIVE: To test the hypothesis that limited paramedic advanced life support skills afford no advantage in survival from cardiac arrest when compared with non-paramedic ambulance crews equipped with defibrillators in an urban environment; and to investigate whether separate response units delayed on scene times. METHODS: A prospective, observational study was conducted over 17 consecutive months on all adult patients brought to the accident and emergency (A&E) department of Glasgow Royal Infirmary having suffered an out of hospital cardiac arrest of cardiac aetiology. The main interventions were bystander cardiopulmonary resuscitation (CPR) and limited advance life support skills. MAIN OUTCOME MEASURES: Return of spontaneous circulation, survival to admission, and discharge. RESULTS: Of 240 patients brought to the A&E department, 19 had no clear record of whether a paramedic was or was not involved and so were excluded. There was no difference in survival between the two groups, although a trend to admission favoured non-paramedics. Paramedics spent much longer at the scene (P < 0.0001). Witnessed arrests (P = 0.01), early bystander CPR (P = 0.12), shockable rhythms (P = 0.003), and defibrillation (P < 0.0001) were associated with better survival. Intubation and at scene times were not associated with better survival. Delayed second response units did not prolong at scene times. CONCLUSIONS: The interventions of greatest benefit in out of hospital cardiac arrest are basic life support and defibrillation. Additional skills are of questionable benefit and may detract from those of greatest benefit.     

Pneumatic anti-shock garment--does it have a future?

A total of 100 accident and emergency (A&E) departments in the UK responded to a questionnaire about their use of the pneumatic anti-shock garment (PASG). Less than one in 10 departments used PASG in their prehospital care system, less than one in five departments used PASG during in-patient care, and there was wide variation in PASG usage in those situations for which their use is recommended by the Advanced Trauma Life Support (ATLS) course.     

How well do doctors resuscitate patients with haemorrhagic shock?

Patients with haemorrhagic shock of all degrees present to accident and emergency (A&E) departments regularly. This study examined 43 such patients who presented to one department over a 14-week period. The adequacy of their fluid replacement was judged in comparison with Advanced Trauma Life Support (ATLS) recommendations according to the degree of shock they appeared to have on presentation. The study found that more training may be required on the appropriate recognition and treatment of haemorrhagic shock.     

Decision making in resuscitation from out of hospital cardiac arrest.

OBJECTIVE--To determine which factors are perceived by senior house officers (SHOs), consultants, and medical registrars in accident and emergency (A&E) medicine as being important in decision making. METHODS--132 SHOs in A&E medicine, of 172 attending an induction course at the start of their job (77%), completed a questionnaire relating to 20 factors of possible importance in decision making; 73 completed the questionnaire at six weeks and 55 at six months. Ten medical registrars and 31 consultants in A&E medicine also completed the questionnaire. RESULTS--The SHOs were able to recognise bystander cardiopulmonary resuscitation and early advanced I support, as well as the presence of ventricular fibrillation, as important prognostic factors. There was considerable variation in all three groups in their opinions on the importance of the other factors considered. There was no obvious change in SHO responses over the period of training. CONCLUSIONS--Lack of guidelines may result in more patients receiving resuscitation than are salvageable, as doctors maintain a low threshold for continuing resuscitation to avoid missing potential survivors. A decision making algorithm is recommended.     

Simulated pediatric cardiopulmonary resuscitation: initial events and response times of a hospital arrest team

BACKGROUND: Cardiopulmonary resuscitation (CPR) training programs exist to enhance knowledge and skills retention. However, they do not ensure that effective CPR will be performed by trainees or resuscitation teams. One aspect of CPR effectiveness is the ability of the team to respond to an emergency call in a timely manner. METHODS: We prospectively evaluated the time required for team members to respond to an emergency call and to initiate definitive treatment in our pediatric facility. The medical staff who responded had no prior knowledge of the simulated cardiac arrest (SCA) events. All events were recorded on audio-cassette tape to determine the sequence of events and response time of arrest team members. SCA scenarios represented examples of cardiac, hematologic, renal, respiratory, and pharmacologic pathophysiology. All participants were instructed to respond as though the SCA were an actual emergency. RESULTS: From December 1991 to January 1993, 37 SCAs were evaluated. Documentation began after a concise arrest scenario had been presented to a designated nursing representative who was to be the first rescuer on the scene. The rescuer first assessed the patient's condition, activated the cardiac arrest system (median elapsed time, MET, 0.50 minutes), and then initiated single-person CPR (MET 0.58 minutes). Administration of oxygen occurred at an MET of 2.25 minutes. The first member of the arrest team to respond was the pediatric resident (MET 3.17 minutes) followed by the respiratory therapist (MET 3.20 minutes), an ICU nurse (MET 3.58 minutes), a pharmacist (MET 3.42 minutes), and anesthesiology personnel (MET 4.70 minutes). DISCUSSION: The use of SCAs (termed "Mega Code") serves as an extension of Basic Life Support and Advanced Cardiac Life Support education and provides a valuable learning experience and quality assurance tool. Limitations that might influence patient outcome during an actual in-hospital arrest have led to refinements in our cardiac arrest procedures. Of particular note was the delay in oxygen administration, which may be linked to its omission from the 1986 and 1992 American Heart Association Basic Life Support Guidelines. CONCLUSION: We believe that BLS education for hospital employees should include and emphasize oxygen delivery for resuscitation.     

Progress of the advanced life support courses in Europe and beyond

The Advanced Life Support (ALS) course was designed initially to teach, and thereby enhance the practice and effectiveness of, resuscitation from cardiac arrest. The target candidates were doctors, nurses and paramedics, and particularly those working in areas likely to encounter such an emergency.     

Perceptions of Basic,Advanced, and Pediatric Life Support Training In a United States Medical School

Background

Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and Pediatric Advanced Life Support (PALS) are integral parts of emergency resuscitative care. Although this training is usually reserved for residents, introducing the training in the medical student curriculum may enhance acquisition and retention of these skills.

Objectives

We developed a survey to characterize the perceptions and needs of graduating medical students regarding BLS, ACLS, and PALS training.

Methods

This was a study of graduating 4^th-year medical students at a U.S. medical school. The students were surveyed prior to participating in an ACLS course in March of their final year.

Results

Of 152 students, 109 (71.7%) completed the survey; 48.6% of students entered medical school without any prior training and 47.7% started clinics without training; 83.4% of students reported witnessing an average of 3.0 in-hospital cardiac arrests during training (range of 0–20). Overall, students rated their preparedness 2.0 (SD 1.0) for adult resuscitations and 1.7 (SD 0.9) for pediatric resuscitations on a 1–5 Likert scale, with 1 being unprepared. A total of 36.8% of students avoided participating in resuscitations due to lack of training; 98.2%, 91.7%, and 64.2% of students believe that BLS, ACLS, and PALS, respectively, should be included in the medical student curriculum.

Conclusions

As per previous studies that have examined this topic, students feel unprepared to respond to cardiac arrests and resuscitations. They feel that training is needed in their curriculum and would possibly enhance perceived comfort levels and willingness to participate in resuscitations.     

Use and effect of paediatric advanced life support skills for paediatric arrest in the A&E department.

OBJECTIVES: To define the use of paediatric advanced life support by the Leicestershire Ambulance and Paramedic Service (LAPS) and the A&E department of a large university teaching hospital; and to identify the outcome and determine the factors that are consistent with a successful outcome. SUBJECTS AND METHODS: The prehospital, accident and emergency (A&E), and inpatient notes of all patients aged 0-16 years who had been admitted to the resuscitation room at the Leicester Royal Infirmary in cardiac arrest between 1 January 1992 and 31 December 1995 were reviewed. Cardiac arrest was defined according to the Utstein template for reporting of prehospital data. RESULTS: During the four year period, 51 cases of paediatric cardiac arrest were identified, with a median age of 3.2 years (range two days to 15 years). In eight patients, resuscitation was not attempted. Of the remaining 43, 15 (37%) were discharged from A&E to the intensive care unit. Five (11.5%) ultimately survived to discharge from hospital. Subsequent neurological development was recorded as normal in four of the five. Of the patients who had a prehospital cardiac arrest and were initially resuscitated by the LAPS there was only one survivor. He was discharged from hospital with severe neurological injury and died three months later. CONCLUSIONS: The outcome for established prehospital paediatric cardiac arrest, in a well defined emergency medical services system, is very poor at present. It does not seem to be affected by the institution of paediatric life support teaching programmes for hospital staff alone. The timing in instituting advanced life support measures remains the most critical factor affecting outcome in these patients.     

Assessment of the effect of Advanced Paediatric Life Support training on level of self‐perceived preparedness among health‐care workers in Cambodia

Objective: The objective of this study was to survey the self‐perceived preparedness of Cambodia's Advanced Paediatric Life Support (APLS) providers towards their APLS training and accreditation 5 years post‐implementation. Methods: A cross‐sectional survey was administered in December 2009 to APLS providers who had been trained throughout the 5 year period from December 2005 to May 2009. Results: One hundred and two (93%) APLS providers responded. The median rating for their original APLS learning experience was 6 out of 10, and the reported median recall of the APLS teaching content was 7 out of 10. Since their training, 80% had managed a child in cardiac arrest, 85% a child with serious illness and 72% with serious injury. Their subjective preparedness from APLS training for each of the three resuscitation types, on a scale of 1–10, were medians of 7, 7 and 6, respectively. For all groups, perceived preparedness for all three resuscitation types did not differ despite varying lengths of time from their original training. Conclusion: APLS training has increased the self‐perceived preparedness of paediatric health‐care workers in Cambodia. Results indicate moderate relevance to real patient resuscitations experienced by health workers, and the perceived recall of the teachings and sense of preparation from APLS training does not significantly decline over time. However, our results suggest subsequent further APLS instructor courses might maintain resuscitation preparedness.     

Doctor-based basic cardiopulmonary resuscitation course: an alternative to the conventional approach

United Christian Hospital initiated a doctor-based cardiopulmonary resuscitation (CPR) Program. It is a two-hour, focused, adult CPR course, suitable for adults of different age groups and of different educational levels. The course was rated highly by the participants. Most trainees acquired CPR knowledge and skills, and had confidence to perform CPR. This type of training could improve the rate of bystander CPR for out-of-hospital cardiac arrest patients in this region. Avoiding the complexity and pass-fail psychology that is used in the traditional CPR training curriculum, it can be an alternative to the traditional four-hour instructor-based Basic Life Support (BLS) course.     

A forgotten need: paediatric resuscitation training

This article highlights the fact that there are currently no real official recommendations regarding the provision of paediatric resuscitation training in the UK. All too often, this teaching features as no more than an ‘add on’ to adult resuscitation sessions. This is a thoroughly inadequate situation as the relatively infrequent occurrence and different aetiology of paediatric arrests necessitates specific training, based on standard guidelines, and adapted to meet the needs of the various groups who have contact with children. A three-tiered package of training is recommended, starting with nationwide paediatric Basic Life Support (BLS) training for the general public. In addition to BLS, healthcare personnel need to be trained in appropriate use of airway adjuncts. Paediatric Advanced Life Support (ALS) is also essential for all medical, nursing and paramedical staff who come into contact with acutely-ill children. In an attempt to address the need for ALS, the PALS (Paediatric Advanced Life Support) course, has been implemented in the UK. Adapted from the American PALS course, it aims to provide appropriate personnel with a systematic, research-based approach to acutely-ill children in emergency situations.     

Should nurses be allowed to request X-rays in an accident & emergency department?

A prospective study was carried out during the month of November, 1990 in the A&E Department, St John's Hospital, Livingston in order to assess the extended role of the A&E nurse and their ability to request X-rays prior to patients being seen by a doctor. A total of 579 randomly selected patients were triaged by A&E Department nurses. Almost 3/4 of these patients were X-rayed at the request of the triage nurse. Less than 7% of these X-rays were considered to have been unnecessary by the doctor who subsequently managed the patient. Of those patients who had an X-ray after seeing a doctor, more than 90% fell within the X-ray triage criteria but had not had an X-ray requested by the triage nurse. Overall, nurses were shown to request X-rays correctly and efficiently with the result that patients had to spend less time in the A&E Department.     

Quality of cardio-pulmonary resuscitation (CPR) during paediatric resuscitation training: Time to stop the blind leading the blind

AimsRecent evidence suggested that the quality of cardio-pulmonary resuscitation (CPR) during adult advanced life support training was suboptimal. This study aimed to assess the CPR quality of a paediatric resuscitation training programme, and to determine whether it was sufficiently addressed by the trainee team leaders during training.MethodsCPR quality of 20 consecutive resuscitation scenario training sessions was audited prospectively using a pre-designed proforma. A consultant intensivist and a senior nurse who were also Advanced Paediatric Life Support (APLS) instructors assessed the CPR quality which included ventilation frequency, chest compression rate and depth, and any unnecessary interruption in chest compressions. Team leaders’ response to CPR quality and elective change of compression rescuer during training were also recorded.ResultsAirway patency was not assessed in 13 sessions while ventilation rate was too fast in 18 sessions. Target compression rate was not achieved in only 1 session. The median chest compression rate was 115 beats/min. Chest compressions were too shallow in 10 sessions and were interrupted unnecessarily in 13 sessions. More than 50% of training sessions did not have elective change of the compression rescuer. 19 team leaders failed to address CPR quality during training despite all team leaders being certified APLS providers.ConclusionsThe quality of CPR performance was suboptimal during paediatric resuscitation training and team leaders-in-training had little awareness of this inadequacy. Detailed CPR quality assessment and feedback should be integrated into paediatric resuscitation training to ensure optimal performance in real life resuscitations.     

Immediate Cardiac Life Support (ICLS) course developed by Japanese Association for Acute Medicine

The Immediate Cardiac Life Support (ICLS) course was developed and launched by Japanese Association for Acute Medicine (JAAM) for resident training, in April 2002. The ICLS course is designed as multi-professional one-day (8 hours) resuscitation course and teaches the essential skills and team dynamics required to manage a patient in cardiac arrest for 10 minutes before the arrival of a cardiovascular specialist. The course consists of skill stations and scenario stations. The skill stations provide basic life support (BLS) with automated external defibrillator (AED), basic airway management and in-hospital management with electrocardiographic (ECG) monitoring with manual external defibrillator. In total, 117,246 candidates attended 6,971 ICLS courses until the end of December 2010. Furthermore, we developed additional course of ICLS to manage stroke, Immediate Stroke Life Support (ISLS). We also describe the development and structure of, and rationale for the ICLS course.     

Major incidents: training for on site medical personnel.

OBJECTIVE: To assess the present levels of training for the medical incident officer (MIO) and the mobile medical team leader (MMTL) throughout the UK. METHOD: Postal questionnaire to consultants in charge of accident and emergency (A&E) departments seeing more than 30,000 patients a year. Information regarding MIO staffing and training and MMTL training and provision requested. RESULTS: A&E provides the majority of both MIOs and MMTLs in the event of a major incident. Virtually all MIOs are consultants or general practitioners. However, 63% of MMTLs are from hospital training grade staff. One third of hospitals required their designated MIO to have undertaken a Major Incident Medical Management and Support course and a quarter had no training requirement at all. Two thirds of MMTLs were expected to have completed an Advanced Trauma Life Support course, but in 21% there was no minimum training requirement. Training exercises are infrequent, and hence the exposure of any one individual to exercises will be minimal. CONCLUSION: There has been some improvement in major incident training and planning since 1992, but much remains to be done to improve the national situation to an acceptable standard.