The knowledge and perceptions of medical personnel relating to outcome after cardiac arrest

OBJECTIVE: We sought to evaluate the knowledge of probable outcome by medical personnel for in-hospital and out-of-hospital cardiac arrests, and self-reported history of CPR training referrals for family members of cardiac patients. METHODS: One hundred people from each of three population lists were randomly selected at a large, urban school of medicine and affiliated medical center: (1) year III and IV medical students; (2) residents in family medicine, emergency medicine, internal medicine, anesthesia, and surgery; (3) attending physicians in the same departments. A questionnaire was distributed that elicited estimates of in-hospital and out-of-hospital cardiac arrest (IHCA and OHCA, respectively) survival rates, and CPR training referral history. Estimates were compared against published data for accuracy (IHCA: 5-20%; OHCA 1-10%) RESULTS: The overall response rate was 63%. Accurate in-hospital cardiac arrest estimates [% (95% CI)] of survival were provided by 51.1% (36.8-63.4%), 47.3% (35.9-58.7%), and 36.7% (23.2-50.2%) of students, residents, and attending physicians, respectively. Accurate out-of-hospital estimates of survival were provided by 51.1% (36.8-63.4%), 52.1% (40.6-63.5%), and 70.8% (57.9-83.7%), respectively. Most thought that family members of cardiac patients ought to be CPR trained (92.6%). However, few had referred any for training in the past year (16.5%). There was strong support across respondent groups for including death notification information in the ACLS training program, with 80.4% of all respondents in favor. CONCLUSIONS: This study demonstrates that medical experience is not associated with accurate estimates of cardiac arrest survival. Overwhelmingly, medical personnel believe family members should be trained to perform CPR, however, few refer family members for CPR training.     

Evaluating Barriers to Bystander CPR among Laypersons before and after Compression-only CPR Training

Objective: Bystander CPR is an essential part of out-of-hospital cardiac arrest (OHCA) survival. EMS and public safety jurisdictions have embraced initiatives to teach compression-only CPR to laypersons in order to increase rates of bystander CPR. We examined barriers to bystander CPR amongst laypersons participating in community compression-only CPR training and the ability of the training to alleviate these barriers. The barriers analyzed include fear of litigation, risk of disease transmission, fear of hurting someone as a result of doing CPR when unnecessary, and fear of hurting someone as a result of doing CPR incorrectly. Methods: Laypersons attending community compression-only CPR training were administered surveys before and after community CPR training. Data were analyzed via standard statistical analyses. Results: A total of 238 surveys were collected and analyzed between September 2015 and January 2016. The most common reported motivation for attending CPR training was “to be prepared/just in case” followed by “infant or child at home.” Respondents reported that they were significantly more likely to perform CPR on a family member than a stranger in both pre-and post-training responses. Nevertheless, reported self-confidence in and likelihood of doing CPR on both family and strangers increased from pre-training to post-training. There was a statistically significant decrease in reported likelihood of all four barriers to prevent respondents from performing bystander CPR when pre-training responses were compared to post-training responses. Previous CPR training and history of having witnessed a sudden cardiac arrest (SCA) were both associated with decreased barriers to CPR, but previous training had no effect on reported likelihood of or confidence in performing CPR. Conclusion: The training initiative studied significantly reduced the reported likelihood of all barriers studied to prevent respondents from performing bystander CPR and also increased the reported confidence in doing CPR and likelihood of doing CPR on both strangers and family. However, it did not alleviate the pre-training discrepancy between likelihood of performing CPR on strangers versus family. Previous CPR training or certification had no impact on likelihood of or confidence in performing CPR.     

Estimating cost-effectiveness of mass cardiopulmonary resuscitation training strategies to improve survival from cardiac arrest in private locations

Introduction

Most cardiopulmonary resuscitation (CPR) trainees are young, and most cardiac arrests occur in private residences witnessed by older individuals.

Objective

To estimate the cost-effectiveness of a CPR training program targeted at citizens over the age of 50 years compared with that of current nontargeted public CPR training.

Methods

A model was developed using cardiac arrest and known demographic data from a single suburban zip code (population 36,325) including: local data (1997-1999) regarding cardiac arrest locations (public vs. private); incremental survival with CPR (historical survival rate 7.8%, adjusted odds ratio for CPR 2.0); arrest bystander demographics obtained from bystander telephone interviews; zip code demographics regarding population age and distribution; and $12.50 per student for the cost of CPR training. Published rates of CPR training programs by age were used to estimate the numbers typically trained. Several assumptions were made: 1) there would be one bystander per arrest; 2) the bystander would always perform CPR if trained; 3) cardiac arrest would be evenly distributed in the population; and 4) CPR training for a proportion of the population would proportionally increase CPR provision. Rates of arrest, bystanders by age, number of CPR trainees needed to result in increased arrest survival, and training cost per life saved for a one-year study period were calculated.

Results

There were 24.3 cardiac arrests per year, with 21.9 (90%) occurring in homes. In 66.5% of the home arrests, the bystander was more than 50 years old. To yield one additional survivor using the current CPR training strategy, 12,306 people needed to be trained (3,510 bystanders aged ≤50 years and 8,796 bystanders aged >50 years), which resulted in CPR provision to 7.14 additional patients. The training cost per life saved for a bystander aged ≤50 years was $313,214, and that for a bystander aged >50 years was $785,040. Using a strategy of training only those ≤50 years, 583 elders per cardiac arrest would need to be trained, with a cost of $53,383 per life saved.

Conclusion

Using these assumptions, current CPR training strategy is not a cost-effective intervention for home cardiac arrests. The high rate of elders witnessing CPR mandates focused CPR interventions for this population.     

NAEMSP 2001 A NNUAL M EETING

Abstract

Recently, emphasis has been placed on the simultaneous implementation of resuscitation interventions currently recommended within the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). The rate of successful outcomes from out-of-hospital cardiac arrest remains relatively low in most U.S. communities. Accurate measures of these rates are difficult to determine because of ineffective reporting mechanisms. In many cases of acute myocardial infarction, the initial presentation of symptoms is quickly followed by sudden death. Little information exists regarding the system-of-care components most likely to result in successful outcomes. Inconsistent application of these components may be responsible in part for the variability of survival rates among communities. We present a case of acute myocardial infarction followed by sudden cardiac arrest benefiting from the application of coordinated, community-based systems of care.     

心肺复苏教学及实践智能化辅助技术的研究进展

心肺复苏(cardiopulmonary resuscitation,CPR)是抢救生命的关键技术之一。本文旨在多方面探究CPR培训的智能化研究现状,并为未来CPR教学和实践的智能化发展方向提供建议。在web of science核心库近五年的文章中搜索CPR训练和CPR智能化设备,获得31篇相关文献。CPR智能化涉及教学、辅助、统计和监测等多方面。现实增强(AR)技术满足了CPR培训互动中环境模拟等新需求。智能设备及新算法提高CPR的培训质量。本文简述了应对心脏骤停一些需要注意的问题。健全的急救保障系统对提高心脏骤停患者的生存率具有很大帮助。     

心肺复苏教学及实践智能化辅助技术的研究进展

心肺复苏(cardiopulmonary resuscitation,CPR)是抢救生命的关键技术之一。本文旨在多方面探究CPR培训的智能化研究现状,并为未来CPR教学和实践的智能化发展方向提供建议。在web of science核心库近五年的文章中搜索CPR训练和CPR智能化设备,获得31篇相关文献。CPR智能化涉及教学、辅助、统计和监测等多方面。现实增强(AR)技术满足了CPR培训互动中环境模拟等新需求。智能设备及新算法提高CPR的培训质量。本文简述了应对心脏骤停一些需要注意的问题。健全的急救保障系统对提高心脏骤停患者的生存率具有很大帮助。     

Training rates and willingness to perform CPR in King County, Washington: a community survey

Background

It has been hypothesized that high rates of cardiopulmonary resuscitation (CPR) training in a community will lead to improved survival for out-of-hospital cardiac arrest. However, factors to consider when designing a far-reaching community CPR training program are not well defined. We explored factors associated with receiving CPR training in the survey community and characteristics contributing to willingness to perform CPR in an emergency.

Methods

A telephone survey was administered to 1001 randomly selected residents in September 2008 assessing CPR training history, demographics, and willingness to perform CPR. Characteristics of survey respondents were compared to examine factors that may be associated with reports of being trained compared to reports of never being trained. A stratified analysis compared characteristics of respondents who reported a high level of willingness to perform CPR in those trained compared to those never trained.

Results

The survey response rate was 39%. Seventy-nine percent of survey respondents reported ever attending a CPR training class. A majority of people (53%) attended their most recent class more than five years ago. People who had never been trained in CPR were older, were more likely to be men and were less likely to have at least a 2-year college degree than those who had ever been trained. Among those who had been trained, younger age, male gender, time of last training and number of times trained were all significantly associated with willingness to perform CPR and none of these factors were associated with willingness in those who had not been trained.

Conclusions

Retraining rates, methods for reaching underserved populations and measures that will improve the likelihood that bystanders will perform CPR in an emergency should be considered when designing a community CPR education program.     

Bolus thrombolytic infusion during prolonged refractory cardiac arrest of undiagnosed cause

Acute myocardial infarction (AMI) and pulmonary embolism (PE) account for about 70% of cardiac arrest. Although thrombolytic therapy is an effective therapy for both AMI and PE, it is not routinely recommended during cardiopulmonary resuscitation (CPR) for fear of life threatening bleeding complications. Numerous case reports and retrospective studies have suggested a beneficial effect of thrombolytics in cardiac arrest secondary to AMI and PE; however, we present a case of successful use of bolus thrombolytics during CPR in a patient with undifferentiated cardiac arrest (undiagnosed cause) after prolonged conventional resuscitation without success.     

Socioeconomic Status Is Associated with Provision of Bystander Cardiopulmonary Resuscitation

Objective. Although socioeconomic status (SES) has been linked to multiple health outcomes, there have been few studies of the effect of SES on the provision of bystander cardiopulmonary resuscitation (CPR) during cardiac arrest events and no studies that we know of on the effect of SES on the provision of dispatcher-assisted bystander CPR. This study sought to define the relationship between SES and the provision of bystander CPR in an emergency medical system that includes dispatcher-provided CPR instructions. Methods. This study was a retrospective, cohort analysis of cardiac arrests due to cardiac causes occurring in private residences in King County, Washington, from January 1, 1999, to December 31, 2005. We used the tax-assessed value of the location of the cardiac arrest as an estimate of the SES of potential bystanders as well as multiple measures from 2000 Census data (education, employment, median household income, and race/ethnicity). We also examined the effect of patient and system characteristics that may affect the provision of bystander CPR. Logistic regression models were used to analyze the association of these factors with two outcomes: the provision of bystander CPR with and without dispatcher assistance. Results. Forty-four percent (1,151/2,618) of cardiac arrest victims received bystander CPR. Four hundred fifty-seven people (17.5% of the entire study population, 39.7% of those who received any bystander CPR) received CPR without telephone instructions. A total of 694 people received dispatcher-assisted bystander CPR (25.6% of the entire population, 60.4% of those receiving any bystander CPR). After adjusting for demographic and care factors, we found a strong association between the tax-assessed value of the cardiac arrest location and increased odds of the provision of bystander CPR without dispatcher instructions and bystander CPR with dispatcher assistance compared with no bystander CPR. Conclusions. This study suggests that higher bystander SES is associated with increased rates of bystander CPR with and without dispatcher instructions. CPR training programs that target lower-SES communities and assessment of these training methods may be warranted.     

Hemodynamics, Survival Benefits, and Complications of Interposed Abdominal Compression during Cardiopulmonary Resuscitation

Objective: To review and describe the hemodynamics and mechanism of benefit of interposed abdominal compression cardiopulmonary resuscitation (IAC-CPR) as well as the current complications and survival data withtheuseoflAC-CPR.
Methods: Critical review of selected, published English-language studies analyzing IAC-CPR. Overview of hemodynamic effects, complications, and survival data of IAC-CPR vs standard CPR.
Results: Several investigators have demonstrated improvements in coronary perfusion pressure, carotid and cerebral blood flows, and augmented venous return using IAC-CPR compared with standard CPR. Recently, IAC-CPR has been shown to improve survival from in-hospital cardiac arrest. To date, there has been no increase in complications seen with the use of abdominal compression during CPR.
Recommendations: IAC-CPR should be considered an adjunct to standard CPR for adult patients experiencing in-hospital cardiac arrest, after an adequate airway has been secured. More research is needed before IAC-CPR can be recommended for out-of-hospital cardiac arrest, for patients who have not been intubated, or for children.     

The feasibility of a novel method of bystander CPR training: A pilot study

Sudden cardiac arrest is a leading cause of death in the United States, with many occurring out of the hospital. Immediate response by bystanders, through the initiation of cardiopulmonary resuscitation (CPR), leads to increased survival; however, many do not respond due to lack of training and education. This study sought to determine the efficacy of a training model developed to rapidly and effectively train large numbers of individuals on hands-only CPR. Thirty minute training sessions were developed to introduce hands-only CPR to faculty at a university, with questionnaires assessing confidence and knowledge of CPR. Faculty then went on to train their respective students. Ninety-six faculty and staff and 1615 students were trained within 3 weeks, demonstrating this model was effective in rapidly training large numbers of individuals in a short period of time while increasing CPR knowledge and confidence. This method may be effective in other community settings.     

Changes in internal medicine residents' attitudes about resuscitation after cardiac arrest over a decade

Background

Resident physicians' beliefs about cardiopulmonary resuscitation (CPR) may impact their communication with patients about end-of-life care. We sought to understand how these perceptions and experiences have changed in the past decade because both medical education and American society have focused more on this domain.

Method

We surveyed 2 internal medicine resident cohorts at a large academic medical center in 1995 and 2005. Residents were asked of their beliefs about survival after CPR, perceived patient understanding, and regret after attempted resuscitation. Residents in 2005 reported more numerical experience with CPR. Current internal medicine residents are more optimistic than the 1995 cohort about survival after an inpatient cardiac arrest. They believe that far fewer patients and families understand resuscitation but report less regret about attempting to resuscitate patients.

Conclusions

These pilot data reveal potential changes in the attitudes of resident physicians toward CPR. The perceived poor understanding among decision makers calls into question the standard of informed consent. Despite this, residents report less regret leading one to ask what factors may underlie this response.     

Public Expectations of Survival Following Cardiopulmonary Resuscitation

Previous studies have demonstrated that the public maintains unrealistic expectations of the potential for successful recovery following administration of cardiopulmonary resuscitation (CPR). Others have attributed this phenomenon to misrepresentation of CPR outcomes on television and other sources of public information. OBJECTIVES: To determine public expectations of CPR and correlate these expectations with various sources of information regarding CPR, including age, television, personal medical training, public programs, friends/family with medical training, and personal experience with CPR. METHODS: A written survey was randomly distributed to local church congregations and completed on a voluntary basis. RESULTS: Ninety-six percent of the respondents expected CPR to be unrealistically effective. Those factors found to increase predicted CPR survival rate were as follows: 1) being under 50 years of age, 2) use of television as a source of information regarding CPR, 3) personal medical training, and 4) use of public programs about CPR. Neither exposure to friends or family with medical training nor personal experience with CPR resulted in increased CPR survival predictions. CONCLUSIONS: Regardless of the source, the public is not accurately informed about the effectiveness of CPR. This creates a situation in which people may elect CPR for themselves or for family members when survival, not to mention recovery, is unlikely. Without dissemination of realistic statistics regarding survival and recovery following CPR, the public will maintain unrealistic expectations of CPR, and be unable to make well-informed decisions concerning its use.     

Resuscitating an idea: prone CPR

Cardiopulmonary resuscitation (CPR) is widely recognized as an essential part of the medical response to cardiac arrest. Traditional ('basic') CPR has remained essentially unchanged for 40 years despite major problems with training and performance, and survival rates from out-of-hospital cardiac arrest remain disappointingly low, despite massive resources devoted to CPR training and public awareness. More than a decade ago, an article described an alternative method-prone CPR-which offered many potential advantages over traditional CPR, including much simpler training and increased likelihood of actual performance by bystanders. The article received little notice at the time; however, the method of prone CPR merits further consideration based on a number of subsequent supporting studies and case reports. Prone CPR may represent a superior alternative to traditional CPR; research into its effectiveness should be given high priority.     

Long-term prognosis after out-of-hospital cardiac arrest and primary percutaneous coronary intervention

AIMS: To study the long-term survival after out-of-hospital cardiac arrest and successful cardiopulmonary resuscitation (CPR) in patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). MATERIAL AND METHODS: In-hospital and 2-year survival of 40 patients treated with primary PCI after out-of-hospital cardiac arrest and STEMI was compared with that of a reference group of 325 STEMI patients, without cardiac arrest, also treated with primary PCI in the same period. RESULTS: In the group with out-of-hospital cardiac arrest, both in-hospital and 2-year mortality was 27.5%. In the reference group, in-hospital and 2-year mortality was 4.9 and 7.1%, respectively. After discharge from hospital there was no significant difference in mortality between the groups. CONCLUSION: Long-term prognosis is good in selected patients after successful out-of-hospital CPR and STEMI treated with primary PCI.     

Eighth grade students become proficient at CPR and use of an AED following a condensed training programme

OBJECTIVE: To evaluate a new, 1-h, condensed training programme to teach continuous chest compression cardiopulmonary resuscitation (CCC-CPR) and automated external defibrillator (AED) skills to a cohort of eight grade public school students. METHODS: RESULTS: Thirty-three eligible subjects completed the programme; mean age 13.7 years; 48.5% female. Eight participants reported some prior training in CPR and AED use. Following initial training, 29/33 (87.8%) subjects demonstrated proficiency at CCC-CPR and AED application/operation in a mock adult cardiac arrest scenario. At four-weeks, 28/33 (84.8%) subjects demonstrated skill retention in similar scenario testing. Subjects also showed improvement in written knowledge regarding AED use as shown by scores on an AHA based written exam (60.9% versus 77.3%; p<0.001). CONCLUSION: With our focused, condensed training program, eighth grade public school students became proficient in CCC-CPR and AED use. This is the first study to document the ability of middle school students to learn and retain CCC-CPR and AED skills for adult sudden cardiac arrest victims with such a curriculum.     

Bystander vs EMS First–responder CPR: Initial Rhythm and Outcome in Witnessed Nonmonitored Out–of–hospital Cardiac Arrest

Objectives: To assess whether outcome and first–monitored rhythm for patients who sustain a witnessed, nonmonitored, out–of–hospital cardiac arrest are associated with on–scene CPR provider group.
Methods: A retrospective, cohort analysis was conducted in a suburban, heterogeneous EMS system. Patients studied were ± 19 years of age, had had an arrest of presumed cardiac origin between July 1989 and January 1993, had gone into cardiac arrest prior to ALS arrival, and had received CPR on collapse. First–monitored rhythms and survival rates were compared for two patient groups who on collapse either: 1) had received CPR by nonprofessional bystanders (BCPR) or 2) had received CPR by on–scene EMS system first responders (FRCPR).
Results: Of 217 cardiac arrest victims, 153 (71%) had received BCPR and 64 (29%) had received FRCPR. The BCPR patients were slightly younger (62. 4 vs 68. 4 years, p = 0. 01) and had slightly shorter ALS response intervals (6. 4 vs 7. 7 minutes, p = 0. 02). There was no difference in BLS response time intervals or automatic external defibrillator (AED) use rates. The percentage of patients with a first–monitored rhythm of pulseless ventricular tachycardia/ventricular fibrillation (VT/VF) and the percentage of patients grouped by CPR provider who survived to hospital admission or to hospital discharge were:
Controlling for age, the odds ratio for VT/VF with BCPR was 5. 45 (95% CI 2. 8, 10. 3).
Conclusion: Patients who receive BCPR more often have a first–monitored rhythm of VT/VF than do FRCPR patients, despite both CPR–provider groups' initiating CPR essentially immediately after patient collapse. Hence, BCPR and FRCPR groups have different first–monitored arrest rhythms, which may affect survival rate. These patient populations should not be considered to be homogeneous groups in CPR research.     

基于Utstein模式的心肺复苏注册单在急诊科的应用

目的探讨基于Utstein模式的心肺复苏注册单在急诊科应用的效果。方法对167例病例进行一般资料登记,回顾审阅167例病历资料中关于心肺复苏的病程描述及医嘱和护理记录,逐一寻找符合注册单中的条目信息并进行登记。将2013年1—9月心脏骤停的48例患者分为实验组,运用注册单前瞻性收集心肺复苏关键数据。实验组的资料收集经过心肺复苏标准化注册培训的临床医务人员在心肺复苏抢救中利用注册单实时记录心肺复苏流程,并按照注册表的质控要求进行数据完善及严格质控。结果注册单应用后心脏骤停时间、心脏骤停病因、CPR启动时间、首次除颤时间、CPR终止时间的记录缺失率较应用前降低,差异均有统计学意义（χ^2值分别为5．92,5．34,203．93,75．16,193．71;P〈0．05）。结论基于Utstein模式的心肺复苏注册单的应用降低了心肺复苏关键数据的缺失率,为心肺复苏质量控制奠定了基础。     

Acute myocardial infarction in the prehospital setting

Despite research and public education, myocardial disease, infarction, and death from cardiac arrest continue to be one of the top public health issues. Many patients experiencing AMIs access health care and receive initial treatment from EMS personnel in the prehospital setting. Prompt identification and diagnosis of these patients, relief of chest pain, and shortening delays to definitive care can decrease morbidity and mortality. Prehospital diagnosis of AMI is enhanced with the use of 12-lead electrocardiograms, which can shorten time to thrombolysis or angiography. Prehospital use of thrombolytic agents has not gained widespread use in this country; it is, however, commonplace in Europe, where research suggests improved outcomes when thrombolysis is initiated prior to hospital arrival. Resuscitation of out-of-hospital cardiac arrest patients is difficult, resulting in dismal survival rates. Factors that appear to be associated with enhanced survival are witnessed arrest, bystander CPR, and short response times to defibrillation.