Cardiopulmonary resuscitation standards for clinical practice and training in the UK

The Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK) have published new resuscitation standards. The document provides advice to UK healthcare organisations, resuscitation committees and resuscitation officers on all aspects of the resuscitation service. It includes sections on resuscitation training, resuscitation equipment, the cardiac arrest team, cardiac arrest prevention, patient transfer, post resuscitation care, audit and research. The document makes several recommendations. Healthcare institutions should have, or be represented on, a resuscitation committee that is responsible for all resuscitation issues. Every institution should have at least one resuscitation officer responsible for teaching and conducting training in resuscitation techniques. Staff with patient contact should be given regular resuscitation training appropriate to their expected abilities and roles. Clinical staff should receive regular training in the recognition of patients at risk of cardiopulmonary arrest and the measures required for the prevention of cardiopulmonary arrest. Healthcare institutions admitting acutely ill patients should have a resuscitation team, or its equivalent, available at all times. Clear guidelines should be available indicating how and when to call for the resuscitation team. Cardiopulmonary arrest should be managed according to current national guidelines. Resuscitation equipment should be available throughout the institution for clinical use and for training. The practice of resuscitation should be audited to maintain and improve standards of care. A do not attempt resuscitation (DNAR) policy should be compiled, communicated to relevant members of staff, used and audited regularly. Funding must be provided to support an effective resuscitation service.     

Nurses and health support workers' views on cardiopulmonary resuscitation in a hospice setting

This paper reports on a study which took place in a 15-bed hospice and provides an account of the views of registered nurses (n = 12) and health support workers (n = 10) in relation to cardiopulmonary resuscitation (CPR) within a hospice setting. The study was part of a larger ethnographic research project being conducted in the hospice when the British Medical Association/Royal College of Nursing and the Resuscitation Council UK (Resuscitation Council UK, 2001) published guidelines urging all establishments that face decisions about attempting CPR to develop local policies. The guidelines provided the impetus for the present study, the aim of which was to explore staff responses to the introduction of a CPR policy in the hospice. Semi-structured interviews were conducted on a purposive sample of hospice staff. The findings raise issues about the implementation of CPR in a context where it was felt that the patient should be allowed to die a natural death.     

Comparison of cardiopulmonary resuscitation techniques using video camera recordings.

OBJECTIVE--To use video recordings to compare the performance of resuscitation teams in relation to their previous training in cardiac resuscitation. METHODS--Over a 10 month period all cardiopulmonary resuscitations carried out in an accident and emergency (A&E) resuscitation room were videotaped. The following variables were monitored: (1) time to perform three defibrillatory shocks; (2) time to give intravenous adrenaline (centrally or peripherally); (3) the numbers and grade of medical and nursing staff involved in the resuscitation; (4) the experience and training of these personnel. RESULTS--Of 101 resuscitations recorded, 69 were carried out by the A&E team alone and 32 by the hospital cardiac arrest team. Resuscitation procedures were carried out significantly more rapidly by the former. Skills and protocols were most effectively used when the resuscitation team was led by an experienced doctor who had received specific training in cardiopulmonary resuscitation, that is, Advanced Life Support course (ALS) or Advanced Cardiac Life Support course (ACLS). Such an individual was always present at A&E team resuscitations but in only 6% of cardiac arrest team resuscitations. CONCLUSIONS--ALS course completion should be regarded as a vital part of the training of any doctor involved in cardiopulmonary resuscitation.     

Nurses' knowledge and skill retention following cardiopulmonary resuscitation training: a review of the literature

AIM: This paper reports a literature review examining factors that enhance retention of knowledge and skills during and after resuscitation training, in order to identify educational strategies that will optimize survival for victims of cardiopulmonary arrest. BACKGROUND: Poor knowledge and skill retention following cardiopulmonary resuscitation training for nursing and medical staff has been documented over the past 20 years. Cardiopulmonary resuscitation training is mandatory for nursing staff and is important as nurses often discover the victims of in-hospital cardiac arrest. Many different methods of improving this retention have been devised and evaluated. However, the content and style of this training lack standardization. METHOD: A literature review was undertaken using the Cumulative Index to Nursing and Allied Health Literature, MEDLINE and British Nursing Index databases and the keywords 'cardiopulmonary resuscitation', 'basic life support', 'advanced life support' and 'training'. Papers published between 1992 and 2002 were obtained and their reference lists scrutinized to identify secondary references, of these the ones published within the same 10-year period were also included. Those published in the English language that identified strategies to enhance the acquisition or retention of Cardiopulmonary resuscitation skills and knowledge were included in the review. RESULTS: One hundred and five primary and 157 secondary references were identified. Of these, 24 met the criteria and were included in the final literature sample. Four studies were found pertaining to cardiac arrest simulation, three to peer tuition, four to video self-instruction, three to the use of different resuscitation guidelines, three to computer-based learning programmes, two to voice-activated manikins, two to automated external defibrillators, one to self-instruction, one to gaming and the one to the use of action cards. CONCLUSIONS: Resuscitation training should be based on in-hospital scenarios and current evidence-based guidelines, including recognition of sick patients, and should be taught using simulations of a variety of cardiac arrest scenarios. This will ensure that the training reflects the potential situations that nurses may face in practice. Nurses in clinical areas, who rarely see cardiac arrests, should receive automated external defibrillation training and have access to defibrillators to prevent delays in resuscitation. Staff should be formally assessed using a manikin with a feedback mechanism or an expert instructor to ensure that chest compressions and ventilations are adequate at the time of training. Remedial training must be provided as often as required. Resuscitation training equipment should be made available at ward/unit level to allow self-study and practice to prevent deterioration between updates. Video self-instruction has been shown to improve competence in resuscitation. An in-hospital scenario-based video should be devised and tested to assess the efficacy of this medium in resuscitation training for nurses.     

Inconsistencies in cardiac arrest reporting

Data relating to survival from in-hospital cardiac arrest are used to audit staff performance and to help to determine whether new resuscitation techniques are effective. Individual studies into outcome from cardiac arrest have defined inclusion and exclusion criteria, but no such national criteria have been published to enable constant auditing of cardiac arrests. The aim of this survey was to investigate the consistency with which in-hospital cardiac arrests are recorded throughout the United Kingdom. Such data are, almost universally, collected by Resuscitation Officers (RO). A questionnaire was sent to ROs across the UK asking them to state how they would interpret and categorise hypothetical, but nonetheless typical, clinical situations involving a cardiac arrest team being called. These included an event where the patient had regained consciousness prior to the arrival of the cardiac team and also an event where rigor mortis was already present and the resuscitation promptly abandoned upon the arrival of the cardiac arrest team. The percentage survival to discharge of adult cardiac arrests for each hospital was also requested. This identified whether inclusion or exclusion of certain clinical events may have influenced cardiac arrest survival figures for that hospital. It is clear from this study that in-hospital clinical events when a cardiac arrest team is called are audited with a great deal of inconsistency. Some events, such as a patient who has rigor mortis, are excluded as a false or inappropriate call in some hospitals and included as an unsuccessful resuscitation in others. There is a need for guidance on the inclusion and exclusion criteria for auditing of cardiac arrests so that meaningful data can be obtained from across the UK and useful conclusions drawn. The situation at present will result in data being audited that are of limited use. In the era of evidence-based medicine, it seems vital to obtain accurate cardiac arrest survival figures in order to have any hope of improving them.     

Communication between members of the cardiac arrest team--a postal survey

Aims: Effective communication enhances team building and is perceived to improve the quality of team performance. A recent publication from the Resuscitation Council (UK) has highlighted this fact and recommended that cardiac arrest team members make contact daily. We wished to identify how often members of this team communicate prior to a cardiopulmonary arrest. Method: A questionnaire on cardiac arrest team composition, leadership, communication and debriefing was distributed nationally to Resuscitation Training Officers (RTOs) and their responses analysed. Results: One hundred and thirty (55%) RTOs replied. Physicians and anaesthetists were the most prominent members of the team. The Medical Senior House Officer is usually nominated as the team leader. Eighty-seven centres (67%) have no communication between team members prior to attending a cardiopulmonary arrest. In 33%, communication occurs but is either informal or fortuitous. The RTOs felt that communication is important to enhance team dynamics and optimise task allocation. Only 7% achieve a formal debrief following a cardiac arrest. Conclusion: Communication between members of the cardiac arrest team before and after a cardiac arrest is poor. Training and development of these skills may improve performance and should be prioritised. Team leadership does not necessarily reflect experience or training.     

A review of simulation-enhanced,team-based cardiopulmonary resuscitation training for undergraduate students

Cardiopulmonary resuscitation training is an essential element of clinical skill development for healthcare providers. The International Liaison Committee on Resuscitation has described issues related to cardiopulmonary resuscitation and emergency cardiovascular care education. Educational interventions have been initiated to try to address these issues using a team-based approach and simulation technologies that offer a controlled, safe learning environment. The aim of the study is to review and synthesize published studies that address the primary question “What are the features and effectiveness of educational interventions related to simulation-enhanced, team-based cardiopulmonary resuscitation training?” We conducted a systematic review focused on educational interventions pertaining to cardiac arrest and emergencies that addressed this main question. The findings are presented together with a discussion of the effectiveness of various educational interventions. In conclusion, student attitudes toward interprofessional learning and simulation experiences were more positive. Research reports emphasized the importance of adherence to established guidelines, adopting a holistic approach to training, and that preliminary training, briefing, deliberate practices, and debriefing should help to overcome deficiencies in cardiopulmonary resuscitation training.     

Paediatric basic life support: a practical assessment.

Current European Resuscitation Council (ERC) guidelines for paediatric basic life support advocate delivery of 20 cycles/min at a compression rate of 100/min and a compression:ventilation ratio of 5:1 (Resuscitation 1997;34:115-27; Resuscitation 1998;37(2):97-100). We have evaluated whether cardiopulmonary resuscitation (CPR) can be delivered at this rate by hospital providers. We recruited 24 rescuers, all of whom had successfully completed a training course in paediatric life support. Each was asked to perform single rescuer CPR on a Resusci-Junior mannequin (Laerdal, Kent, UK) for 5 min, following the current ERC guidelines. Compressions and ventilations were recorded in real time by inductance plethysmography. Maintenance of the 5:1 ratio was ensured by investigator observation. Cycles of CPR in the first and fifth minutes of resuscitation were counted. The average duration of compression, ventilation and 'transfer time' spent between these two activities was calculated as a percentage of the average duration of a cycle of CPR. All 24 rescuers completed 5 min of resuscitation. Twenty-three of 24 were unable to deliver 20 cycles of CPR in either the first minute (range 8-27; median 11; interquartile range (IQR) 10-13.75) or in the fifth minute (8-26; 11.5; 10-13.75). The median (IQR) duration of a cycle of CPR was 5 s in the first and fifth minutes. Transfer time comprised 30% of total cycle time. In this study, over 95% of single rescuers trained in paediatric life support were unable to deliver 20 cycles of CPR/min. The guidelines make no allowance for time spent moving between compression and ventilation activity. Future consensus statements should take account of this transfer time. Any changes in recommendations should obviously be prospectively audited with Utstein-style reporting and studies of practicability.     

Part 9: pediatric basic life support. European Resuscitation Council

The epidemiology and outcome of pediatric cardiopulmonary arrest and the priorities, techniques, and sequence of pediatric resuscitation assessments and intervention differ from those of adults. Current guidelines have been updated after extensive multinational evidence-based review and discussion over several years. Areas of controversy in current guidelines and recommendations made by consensus are detailed. A large degree of uniformity exists in the current guidelines advocated by the AHA, Council on Latin American Resuscitation, Heart and Stroke Foundation of Canada, European Resuscitation Council, Australian Resuscitation Council, and Resuscitation Council of Southern Africa. Differences are currently based on local and regional preferences, training networks, and customs rather than scientific controversy. Unresolved issues with potential for future universal application are highlighted.     

Emergency drug availability for the cardiac arrest team: a national audit

Cardiac arrest teams are called upon to deal with many different acute medical emergencies, including cardiac arrest. However, the drugs that are supplied for them to perform their role differs vastly from hospital to hospital. We have confirmed this in an audit of adult cardiac arrest teams from all the acute hospitals within Wales. The rational use of defibrillation and drugs during cardiopulmonary resuscitation has been standardised according to International guidelines, and there is no reason why resuscitation kits could not also be standardised. Further considerations of drug availability is needed for acute management of other collapsed patients without cardiac arrest, most commonly vaso-vagal syncope, anaphylaxis, hypoglycaemia, fits and respiratory arrest. Based upon recent recommendations from the project team of the Resuscitation Council (UK), augmented by other commonly needed drugs for first aid in the collapsed patient, we propose a reduced and simplified emergency drug list, employing a two box system covering immediate and most secondary requirements. A standardised format of drug kits for use by adult cardiac arrest teams could speed effective delivery of emergency care.     

Transthoracic biphasic waveform defibrillation at very high and very low energies: a comparison with monophasic waveforms in an animal model of ventricular fibrillation

The laryngeal mask airway (LMA) and Combitube have been recommended for use during cardiopulmonary resuscitation (CPR). An overview of current practice was sought by conducting a postal survey of 265 Resuscitation Training Departments, at different hospitals, throughout the UK. One hundred fifty-three (58%) completed questionnaires were returned. Only 38 (25%) hospitals which replied were currently using the LMA in resuscitation while seven (5%) were using the Combitube. The reasons for not using these airway adjuvants included concerns about airway protection, difficulties in training, cost, and the concept that when anaesthetists were available on cardiac arrest teams these devices were unnecessary.     

Resuscitation Guidelines 2005: does experienced nursing staff need training and how effective is it?

Introduction

Even among health care professionals, resuscitation performance has been shown to be poor. So far, it remains unclear whether cardiac arrest staff with frequent practice in resuscitation requires training to adapt to the new International Liaison Committee on Resuscitation (ILCOR) guidelines of 2005. This study evaluated the need for basic life support training in nurses with emergency experience.

Methods and Results

Nurses (N = 24) recruited from an intensive care unit self-assessed their resuscitation skills and performed a cardiac arrest scenario using a manikin. After a theoretical instruction and hands-on training followed by feedback, participants once again performed a resuscitation scenario in addition to completing posttraining self-assessments. Participating nurses considered resuscitation skills training—in particular in adapting to the new ILCOR guidelines of 2005—to be important. Pretraining data revealed performance deficits even in this sample of emergency-experienced nursing staff. Training resulted in significant improvement in ventilation volume (P < .001), rate of compressions with correct depth (P < .031) and full release (P < .001), and a reduction in total hands-off time (P < .050). Objective data were mirrored in participants' self-assessed competencies.

Conclusion

Results suggest that basic life support training based on the ILCOR guidelines of 2005 is necessary even in nurses with emergency experience. Training followed by the application of a feedback algorithm seems to improve short-term resuscitation performance and is well accepted by experienced nurses who work on an intensive care unit and who also comprise the inner-hospital cardiac arrest team.     

Cardiac arrest: the skills of the Emergency Nurse Practitioner

This paper seeks to explore the skills that the Emergency Nurse Practitioner (ENP) should have in relation to cardiopulmonary resuscitation (CPR).No specific literature was found relating to the role of the ENP in CPR. Therefore, three literature searches were carried out and the findings used to suggest skills in which the ENP should be competent.As demand for community based minor injuries units (MIUs) grows, development of an independent role for ENPs should reflect their unique relationship with patients. These patients may have illnesses in addition to the injuries with which they present. If a patient collapses in cardiac arrest, the prompt and correct response of the ENP would be the most important factor in increasing the patient's survival chances (European Resuscitation Council 1992a & b, Handley & Swain 1994).The majority of sudden cardiac arrests are caused by ventricular fibrillation (VF) (Royal College of Physicians 1987). Therefore, competence in defibrillation is one area of nursing role expansion which should be adopted by an ENP during the role transition. This should be supported by biannual training in Basic Life Support (BLS) to ensure that ENPs are able to manage cardiac arrests effectively. Nationally recognized training is recommended in order to facilitate ENP movement between Trusts.     

A survey of resuscitation training needs of senior anaesthetists

Resuscitation skills are a fundamental part of anaesthetic practice. Anaesthetists are involved in performing resuscitation and training of other staff in resuscitation techniques. However, very few senior anaesthetists attend the Resuscitation Council (UK)/European Resuscitation Council [RC (UK)/ERC] advanced life support (ALS) course. We have surveyed the views of consultant anaesthetists in one region of the UK. The results show that although they are involved in training, very few attend cardiac arrests. Most have not, and will not, attend the ALS course but would prefer shorter regular resuscitation updates, especially in those skills that they no longer use.     

In-hospital resuscitation--what should we be teaching?

This paper examines the initial actions that should take place following the sudden collapse of a patient in a hospital. The current Basic Life Support guidelines are not designed for this situation, yet are commonly taught to hospital staff. An alternative algorithm for Hospital Resuscitation has been developed. Additional factors, such as the recognition of the sick patient and the importance of audit should be included in hospital resuscitation training. A tiered approach to resuscitation training within a hospital should be adopted and national standards developed.     

Cardiovascular collapse after amiodarone administration in neonatal supraventicular tachycardia.

Amiodarone is recommended by the International Liaison Committee on Resuscitation and has been adapted by the Resuscitation Council (UK) and the Advanced Life Support Group for use in paediatric advanced life support and advanced paediatric life support for the treatment of refractory supraventricular tachycardia. The International Liaison Committee on Resuscitation has stated that resuscitation guidelines should be evidence based. We present a case report of a cardiovascularly stable infant with supraventricular tachycardia who had a variety of arrthymias requiring cardiopulmonary resucitation for a prolonged period of time after loading with intravenous amiodarone. We believe that this report, together with other evidence, may suggest caution with the use of amiodarone.     

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.     

RECOVER CPR for veterinary nurses

ABSTRACT

This article outlines the Reassessment Campaign on Veterinary Resuscitation (RECOVER) initiative. It will review the established evidence-based guidelines for veterinary CPR, which are internationally recognised and endorsed by the American College of Veterinary Emergency and Critical Care (ACVECC) and Veterinary Emergency and Critical Care Society (VECCS). After reading this article, participants should be able to prepare for and recognise cardiopulmonary arrest (CPA), initiate basic life support, provide advanced life support, monitor the CPA patient and provide post-CPA care. Participants will also have access on the different RECOVER certifications available and certification process.     

The impact of 2010 international consensus on CPR and ECC science with treatment recommendations on Japan

New guidelines on cardiopulmonary resuscitation(CPR) and emergency cardiovascular care (ECC) were published in October 2010 from International Liaison Committee on Resuscitation (ILCOR). Changes of these guidelines will have dramatic effects on Japan. Starting with chest compressions first will increase by-stander CPR. Cases of recovery of spontaneous heartbeat could increase as a result. Intensive care and radical treatments for cardiovascular emergency and brain damage after cardiopulmonary arrest would be essential. Education, implementation and teams (EIT) will be the third subject.     

The immediate life support course

The immediate life support course (ILS) was launched by the Resuscitation Council (UK) in January 2002. This multi-professional 1-day resuscitation course teaches the essential knowledge and skills required to manage a patient in cardiac arrest for the short time before the arrival of a cardiac arrest team or other experienced medical assistance. The ILS course also introduces healthcare professionals to the role of a cardiac arrest team member. The course provides the candidate with the knowledge and skills to recognise and treat the acutely ill patient before cardiac arrest, to manage the airway with basic techniques, and to provide rapid, safe defibrillation using either manual or automated external defibrillators (AEDs). The course includes lectures, skill stations and cardiac arrest scenarios. The ILS course has standardised much of the life support training that already takes place in UK hospitals. In 2002, 16547 candidates attended ILS courses in 128 course centres. In this article, we discuss the rationale for, and the development and structure of the ILS course. We also present the first year's results and discuss possible future developments. It is hoped that this course may become established in counties in continental Europe through the European Resuscitation Council.