Test of a smock system on CPR primary emergency measures and medical errors during simulated emergencies

Rates of survival of victims of sudden cardiac arrest (SCA) using cardio pulmonary resuscitation (CPR) have shown little improvement over the past three decades. Since registered nurses (RNs) comprise the largest group of healthcare providers in U.S. hospitals, it is essential that they are competent in performing the four primary measures (compression, ventilation, medication administration, and defibrillation) of CPR in order to improve survival rates of SCA patients. The purpose of this experimental study was to test a color-coded SMOCK system on: 1) time to implement emergency patient care measures 2) technical skills performance 3) number of medical errors, and 4) team performance during simulated CPR exercises. The study sample was 260 RNs (M 40 years, SD=11.6) with work experience as an RN (M 7.25 years, SD=9.42).Nurses were allocated to a control or intervention arm consisting of 20 groups of 5-8 RNs per arm for a total of 130 RNs in each arm. Nurses in each study arm were given clinical scenarios requiring emergency CPR. Nurses in the intervention group wore different color labeled aprons (smocks) indicating their role assignment (medications, ventilation, compression, defibrillation, etc) on the code team during CPR. Findings indicated that the intervention using color-labeled smocks for pre-assigned roles had a significant effect on the time nurses started compressions (t=3.03, p=0.005), ventilations (t=2.86, p=0.004) and defibrillations (t=2.00, p=.05) when compared to the controls using the standard of care. In performing technical skills, nurses in the intervention groups performed compressions and ventilations significantly better than those in the control groups. The control groups made significantly (t=-2.61, p=0.013) more total errors (7.55 SD 1.54) than the intervention group (5.60, SD 1.90). There were no significant differences in team performance measures between the groups. Study findings indicate use of colored labeled smocks during CPR emergencies resulted in: shorter times to start emergency CPR; reduced errors; more technical skills completed successfully; and no differences in team performance.

Time Delays on the Identification of the Need for CPR for Limited English Proficient 9-1-1 Callers

Thesis (Master's)--University of Washington, 2016-08

Hematoma sublingual espontáneo secundario a terapia anticoagulante con warfarina

Abstract Hemorrhagic complications in oral anticoagulant therapy are frequent. Spontaneous sublingual hematomas secondary to anticoagulants are an extremely unusual complication that is potentially lethal. The study reports a case of a patient on anticoagulation therapy with warfarine who develops a massive, spontaneous sublingual hematoma with obstruction of the high airway and cardiac arrest, where emergency transtracheal catheter ventilation was used.

Śmierć osobnicza (mózgowa) jako przesłanka dopuszczalności przeszczepu ex mortuo

W artykule przedstawiono problematykę śmierci osobniczej (mózgowej) jako przesłanki dopuszczalności przeszczepu ex mortuo. W pierwszej kolejności zostały opisane podstawowe zagadnienia dotyczące pojęcia transplantacji oraz jej rodzajów występujących w piśmiennictwie medycznym. Dalej poruszono tematykę śmierci i jej rodzajów w kontekście transplantacji, podkreślono również występującą w doktrynie różnicę utożsamiania śmierci klinicznej ze śmiercią pozorną, a także przedstawiono występujący w literaturze sztuczny podział śmierci ze względu na narządy, tj. mózg, płuca i serce. Głównym punktem pracy jest zagadnienie śmierci mózgowej (osobniczej). Wskazano wątpliwości natury prawnej, medycznej i społecznej odnośnie do tej przesłanki. Wskazano na metodykę pracy przy ustaleniu śmierci mózgowej. Zwrócono uwagę na fakt zmiany definicji na gruncie obowiązującej ustawy transplantacyjnej. W dalszej kolejności zostało poruszone zagadnienie śmierci wskutek nieodwracalnego zatrzymania krążenia. W podsumowaniu zebrano w sposób ścisły wątki omawiane przez całą pracę i wspominano o innych przesłankach dopuszczalności przeszczepu ex mortuo.

Effects of two teaching interventions on nursing students’ acquisition of competence in ECG interpretation

Purpose: Nurse ability to recognise patient arrhythmias could contribute to preventing in-hospital cardiac arrest. Research suggests that nurses and nursing students lack competence in electrocardiogram (ECG) interpretation. The aim of this study was to compare the effects of two training strategies on nursing students’ acquisition of competence in ECG interpretation. Materials and methods: A controlled randomised trial with 98 nursing students. Divided in groups of 12–16, participants were randomly allocated to one of the following 3-h teaching intervention groups: 1) traditional instructor-led (TILG), and 2) flipped classroom (FCG). Participants’ competence in ECG interpretation was measured in terms of knowledge (%), skills (%) and self-efficacy (%) using a specifically designed and previously validated toolkit at pre-test and post-test. Two-way MANOVA explored the interaction effect between ‘teaching group’ and ‘time of assessment’ and its impact on participants’ competence. Within-group differences at pre-test and post-test were explored by carrying out paired t-tests. Between-group differences at pre- and post-test were examined by performing independent t-test analysis. Results: There was a statistically significant interaction effect between ‘teaching group’ and ‘time of assessment’ on participants’ competence in ECG interpretation (F(3,190) = 86.541, p = 0.001; Wilks’ Λ = 0.423). At pre-test, differences in knowledge (TILG = 35.12 ± 12.07; FCG = 35.66 ± 10.66), skills (TILG = 14.05 ± 10.37; FCG = 14.82 ± 14.14), self-efficacy (TILG = 46.22 ± 23.78; FCG = 40.01 ± 21.77) and all other variables were non-significant (p > 0.05). At post-test, knowledge (TILG = 55.12 ± 14.16; FCG = 94.2 ± 7.31), skills (TILG = 36.90 ± 16.45; FCG = 86.43 ± 14.32) and self-efficacy (TILG = 70.78 ± 14.55; FCG = 79.98 ± 10.35) had significantly improved, regardless of the training received (p < 0.05). Nonetheless, participants in the FCG scored significantly higher than participants in the TILG in knowledge, skills and self-efficacy (p < 0.05). Conclusion: Flipping the classroom for teaching ECG interpretation to nursing students may be more effective than using a traditional instructor-led approach in terms of immediate acquisition of competence in terms of knowledge, skills and self-efficacy. Further research on the effects of both teaching strategies on the retention of the competence will be undertaken.

Effects of two teaching strategies on the relationship between nursing students’ self-efficacy and performance in BLS/AED

Purpose: Nurses and nursing students are often first responders to in-hospital cardiac arrest events; thus they are expected to perform Basic Life Support (BLS) and use an automated external defibrillator (AED) without delay. The aim of this study was to explore the relationship between nursing students’ self-efficacy and performance before and after receiving a particular training intervention in BLS/AED. Materials and methods: Explanatory correlational study. 177 nursing students received a 4-h training session in BLS/AED after being randomized to either a self-directed (SDG) or an instructor-directed teaching group (IDG).1 A validated self-efficacy scale, the Cardiff Test and Laerdal SkillReporter® software were used to assess students’ self-efficacy and performance in BLS/AED at pre-test, post-test and 3-month retention-test. Independent t-test analysis was performed to compare the differences between groups at pre-test. Pearson coefficient (r) was used to calculate the strength of the relationship between self-efficacy and performance in both groups at pre-test, post-test and retention-test. Results: Independent t-tests analysis showed that there were non-significant differences (p-values > 0.05) between groups for any of the variables measured. At pre-test, results showed that correlation between self-efficacy and performance was moderate for the IDG (r = 0.53; p < 0.05) and the SDG (r = 0.49; p < 0.05). At post-test, correlation between self-efficacy and performance was much higher for the SDG (r = 0.81; p < 0.05) than for the IDG (r = 0.32; p < 0.05), which in fact was weaker than at pre-test. Finally, it was found that whereas the correlation between self-efficacy and performance increased from the post-test to the retention-test to almost reach baseline levels for the ILG (r = 0.52; p < 0.05), it slightly decreased in this phase for the SDG (r = 0.77; p < 0.05). Conclusion: Student-directed strategies may be more effective than instructor-directed strategies at promoting self-assessment and, therefore, may help to improve and maintain the relationship between nursing student self-efficacy and actual ability to perform BLS/AED.

Test of a Smock System on CPR Primary Emergency Measures and Medical Errors During Simulated Emergencies

Rates of survival of victims of sudden cardiac arrest (SCA) using cardio pulmonary resuscitation (CPR) have shown little improvement over the past three decades. Since registered nurses (RNs) comprise the largest group of healthcare providers in U.S. hospitals, it is essential that they are competent in performing the four primary measures (compression, ventilation, medication administration, and defibrillation) of CPR in order to improve survival rates of SCA patients. The purpose of this experimental study was to test a color-coded SMOCK system on:1) time to implement emergency patient care measures 2) technical skills performance 3) number of medical errors, and 4) team performance during simulated CPR exercises. The study sample was 260 RNs (M 40 years, SD=11.6) with work experience as an RN (M 7.25 years, SD=9.42).Nurses were allocated to a control or intervention arm consisting of 20 groups of 5-8 RNs per arm for a total of 130 RNs in each arm. Nurses in each study arm were given clinical scenarios requiring emergency CPR. Nurses in the intervention group wore different color labeled aprons (smocks) indicating their role assignment (medications, ventilation, compression, defibrillation, etc) on the code team during CPR. Findings indicated that the intervention using color-labeled smocks for pre-assigned roles had a significant effect on the time nurses started compressions (t=3.03, p=0.005), ventilations (t=2.86, p=0.004) and defibrillations (t=2.00, p=.05) when compared to the controls using the standard of care. In performing technical skills, nurses in the intervention groups performed compressions and ventilations significantly better than those in the control groups. The control groups made significantly (t=-2.61, p=0.013) more total errors (7.55 SD 1.54) than the intervention group (5.60, SD 1.90). There were no significant differences in team performance measures between the groups. Study findings indicate use of colored labeled smocks during CPR emergencies resulted in: shorter times to start emergency CPR; reduced errors; more technical skills completed successfully; and no differences in team performance.

Interventions for nurses caring for a child who has an unexpected acute life threatening event (ALTE) in hospital

Introduction: Caring for a child who has an unexpected ALTE in hospital can be stressful. An ALTE may include a cardiac arrest, respiratory arrest or call for immediate assistance. An international survey of practice was conducted to identify any existing interventions to inform a PhD program of work aimed at reducing the stress from these events through preparation and support. Purpose: The purpose of the survey was threefold: (1) Describe ‘normal’ practice when it comes to preparing staff or providing psychological support after caring for a child who has had an ALTE. (2) Determine if there are any interventions to prepare clinical staff for potential psychological effects of caring for a child who has an ALTE. (3) Determine if there are any interventions to provide support for clinical staff after caring for a child who has an ALTE. Material - Methods: An 18 item semi structured questionnaire was designed for the study to allow respondent to describe practices within their institution and outline their opinions and professional experiences. Clinicians from selected children’s and adult hospitals in Australia, Canada, New Zealand, United Kingdom and the United States of America were contacted by telephone. Following consent they were given the option to complete the survey via the telephone, by post or online. Results: Of the 61 hospitals approached 44 (72%) clinicians responded. Eighteen (41%) respondents identified interventions in place to prepare nurses for an ALTE ranging from (but not limited to) ad hoc discussions during life support training through to structured simulation training. Thirty-six (82%) respondents identified that they had interventions in place to support nurses after an ALTE ranging from (but not limited to) debriefing through to structured case reviews. Conclusions: Interventions varied across institutions, with no outcome or evaluation data for the interventions published to date.

Sjuksköterskestudenters upplevelse av förberedelse inför hjärtstopp : En empirisk studie

Introduktion: Årligen drabbas cirka 15 000 personer av hjärtstopp i Sverige. Sjuksköterskanhar ett stort i ansvar i omvårdnaden vid hjärtstopp. Sjuksköterskeutbildningen strävar efter attförbereda studenterna inför omvårdnad vid hjärtstopp. Syfte: Att belysasjuksköterskestudenters upplevelse av förberedelse inför att utöva omvårdnad av patienter samband med hjärtstopp. Metod: Kvalitativ design med semistrukturerade intervjuer. Undersökningsgruppen bestämdes av bekvämlighetsurval. 16 sjuksköterskestudenter i termin 6 intervjuades och data analyserades med hjälp av innehållsanalys. Resultat: Resultatet avstudien visade på att informanterna kände en otrygghet i sig själva, och var osäkra inför attutföra hjärt- och lungräddning för första gången på grund av bristande erfarenhet samt för litekunskap. Informanterna upplevde dock trygghet när de hade erfarna kollegor runt omkring sigsamt när de hade upplevt en riktig hjärtstoppssituation själva. Slutsats: Utifrån studiens resultatbedöms att sjuksköterskestudenter inte känner sig trygga i sig själva och i sin förmåga att utföraadekvat S-HLR, samt inte upplever sig vara förberedda inför att hantera en hjärtstoppssituation.

The importance of physical fitness in the performance of adequate cardiopulmonary resuscitation

The aim of the present investigation was to evaluate the influence of the physical fitness of a cardiopulmonary resuscitation (CPR) provider on the performance of and physiologic response to CPR. To this end, comparisons were made of sedentary and physically active subjects in terms of CPR performance and physiologic variables. Two study groups were established: group P (n = 14), composed of sedentary, professional CPR rescuers (mean [± SD]; age, 34 ± 6 years; V̇O2max, 32.5 ± 5.5 mL/kg/min), and group Ex (n = 14), composed of physically active, nonexperienced subjects (age, 34 ± 6 years; V̇O2max, 44.5 ± 8.5 mL/kg/min). Each subject was required to perform an 18-min CPR session, which involved manual external cardiac compressions (ECCs) on an electronic teaching mannequin following accepted standard CPR guidelines. Subjects' gas exchange parameters and heart rates (HRs) were monitored throughout the trial. Variables indicating the adequacy of the ECCs (ECC depth and the percentage of incorrect compressions and hand placements) also were determined. Overall CPR performance was similar in both groups. The indicators of ECC adequacy fell within accepted limits (ie, an ECC depth between 38 and 51 mm). However, fatigue prevented four subjects from group P from completing the trial. In contrast, the physiologic responses to CPR differed between groups. The indicators of the intensity of effort during the trial, such as HR or percentage of maximum oxygen uptake (V̇O2max) were higher in group P subjects than group Ex subjects, respectively (HRs at the end of the trial, 139 ± 22 vs 115 ± 17 beats/min, p < 0.01; percentage of V̇O2max after 12 min of CPR, 46.7 ± 9.7% vs 37.2 ± 10.4%, p < 0,05). These results suggest that a certain level of physical fitness may be beneficial to CPR providers to ensure the adequacy of chest compressions performed during relatively long periods of cardiac arrest.

SOCIAL REPRESENTATIONS OF BASICS LIFE SUPPORT

Victims of cardiac arrest need immediate Basic Life Support, in order to preserve as much as possible, the flow of blood to the brain and heart and other vital organs, it is essential to gain time pending differentiated help, performing simple acts and practical (BLS) to save lives. Learn how to perform RPC is an interactive process that requires knowledge and skills, but at the same time an act of solidarity, social responsibility, civic consciousness, and a duty of citizenship. Because no one revives alone, it requires a coordinated work of a team, all citizens must join forces in a single goal: Save Lives, the massification of the BLS (RPC, 2014). We conducted an exploratory study that aimed to identify the social representations of basic life support in the general population. We used the technique of free association of words through a short questionnaire, we obtained a sample of 45 participants. The results show that participants were mostly female and 27 that fashion of age was in the age group 40 to 59 years. With regard to social representations, we find an organized structure follows the core: help, help to revive, and save is giving life, are in fact structural and consensual elements in basic life support. In more peripheral elements we find extremely important elements, which can be worked in a way so that the core is more efficient such as to act coordinately as a team in face of an accident, it can thus be successful in practice. The social representation of basic life support does not differ from that referred in the literature on the subject, but it is common knowledge that these skills can only be acquired if they are systematically trained, because they obey an algorithm that if it is not settled theoretical and instrumentally it is not effective in practice.

Outflow occlusion for circulatory arrest in dogs

The purpose of this study was to evaluate the possibility of producing circulatory arrest by occlusion of the pulmonary trunk as an alternative to the venous inflow occlusion through the left hemithorax. Eight healthy mongrel dogs were divided in two groups. Group I underwent 4 minutes of outflow occlusion and Group II was submitted to 8 minutes of circulatory arrest. Outflow occlusion was performed through left thoracotomy and pericardiotomy by passing a Rumel tourniquet around the pulmonary trunk. Physical examination, electrocardiography, echocardiography, blood gas analyses, hemodynamic, and oxygen transport variables were obtained before and after the procedure. The dogs from Group I did not have any clinical, electrocardiographic, echocardiographic, or hemo-dynamic abnormalities after anesthetic recover. In the Group II, only one dog survived, which had no clinical, electrocardiographic, or echocardiographic abnormalities. In this last dog, just after releasing the occlusion, it was detected increases in the following parameters: heart rate (HR), systolic, diastolic and mean arterial blood pressure (SAP; DAP; MAP), pulmonary artery pressure (PAP), pulmonary wedge pressure (PWP), central venous pressure (CVP), cardiac output (CO), systolic index (SI), cardiac index (CI), left and right ventricular stroke work (LVSW; RVSW), oxygen delivery index (DO2), oxygen consumption index (VO2), and oxygen extraction (O2 ext). Moreover, the oxygen content of arterial and mixed venous blood (CaO2; CvO2), and the arterial and mixed venous partial pressure of oxygen (PaO2; PvO2) were decreased 5 minutes after circulatory arrest. Outflow occlusion is a feasible surgical procedure for period of 4 minutes of circulatory arrest.

Comparisons of the release of vasodilator substances from left and right cardiac chambers of the isolated perfused rabbit heart: Implications for intraventricular thrombus formation

Prostacyclin (PgI(2)) and endothelium-derived nitric oxide (EDNO) are produced by the arterial and venous endothelium. In addition to their vasodilator action on vascular smooth muscle, both act together to inhibit platelet aggregation and promote platelet disaggregation. EDNO also inhibits platelet adhesion to the endothelium. EDNO and PgI(2) have been shown to be released from the cultured endocardial cells. In this study, we examined the release of vasoactive substances from the intact endocardium by using isolated rabbit hearts perfused with physiological salt solution (95% O(2)/5% CO(2), T = 37 degrees C). The right and left cardiac chambers were perfused through separate constant-flow perfusion loops (physiological salt solution, 8 ml min(-1)). Effluent from left and right cardiac, separately, was bioassayed on canine coronary artery smooth muscle, which had been contracted with prostaglandin F(2 alpha_)(2 x 10(-6) M) and no change in tension was exhibit. However, addition of calcium ionophore A23187 (10(-6) M) to the cardiac chambers` perfusion line induced vasodilation of the bioassay coronary ring, 61.4 +/- 7.4% versus 70.49 +/- 6.1% of initial prostaglandin F(2 alpha) contraction for the left and right cardiac chambers perfusate, respectively (mean +/- SEM, n = 10, p > 0.05). Production of vasodilator was blocked totally in the left heart but, only partially blocked in the right heart by adding indomethacin (10(-5) M) to the perfusate, respectively, 95.2 +/- 2.2% versus 41.5 +/- 4.8% (mean +/- SEM, n = 10, p < 0.05). 6-Keto prostaglandin F(1 alpha), measured in the endocardial superfusion effluent was also higher for the left cardiac chambers than for the right at the time of stimulation with the A23187, respectively, 25385.88 +/- 5495 pg/ml (n = 8) versus 13,132.45 +/- 1839.82 pg/ml (n = 8), (p < 0.05). These results showed that cyclooxygenase pathway plays major role in generating vasoactive substances for the left cardiac chamber endocardium; while it is not the main pathway for the right ventricular endocardium at which EDNO and PgI(2) Could act together and potentiate their antithrombogenic activities in isolated perfused rabbit heart. This may be an explanation for the intraventricular thrombus mostly seen in left ventricle rather than in right ventricle as a complication of myocardial infarction. (C) 2009 Elsevier Inc. All rights reserved.

Cardiopulmonary support and extracorporeal membrane oxygenation for cardiac assist.

BACKGROUND: Use of cardiopulmonary bypass for emergency resuscitation is not new. In fact, John Gibbon proposed this concept for the treatment of severe pulmonary embolism in 1937. Significant progress has been made since, and two main concepts for cardiac assist based on cardiopulmonary bypass have emerged: cardiopulmonary support (CPS) and extracorporeal membrane oxygenation (ECMO). The objective of this review is to summarize the state of the art in these two technologies. METHODS: Configuration of CPS is now fairly standard. A mobile cart with relatively large wheels allowing for easy transportation carries a centrifugal pump, a back-up battery with a charger, an oxygen cylinder, and a small heating system. Percutaneous cannulation, pump-driven venous return, rapid availability, and transportability are the main characteristics of a CPS system. Cardiocirculatory arrest is a major predictor of mortality despite the use of CPS. In contrast, CPS appears to be a powerful tool for patients in cardiogenic shock before cardiocirculatory arrest, requiring some type of therapeutic procedures, especially repair of anatomically correctable problems or bridging to other mechanical circulatory support systems such as ventricular assist devices. CPS is in general not suitable for long-term applications because of the small-bore cannulas, resulting in significant pressure gradients and eventually hemolysis. RESULTS: In contrast, ECMO can be designed for longer-term circulatory support. This requires large-bore cannulas and specifically designed oxygenators. The latter are either plasma leakage resistent (true membranes) or relatively thrombo-resistant (heparin coated). Both technologies require oxygenator changeovers although the main reason for this is different (clotting for the former, plasma leakage for the latter). Likewise, the tubing within a roller pump has to be displaced and centrifugal pump heads have to be replaced over time. ECMO is certainly the first choice for a circulatory support system in the neonatal and pediatric age groups, where the other assist systems are too bulky. ECMO is also indicated for patients improving on CPS. Septic conditions are, in general, considered as contraindications for ECMO. CONCLUSIONS: Ease of availability and moderate cost of cardiopulmonary bypass-based cardiac support technologies have to be balanced against the significant immobilization of human resources, which is required to make them successful.

Why bystanders decline telephone cardiac resuscitation advice.

OBJECTIVES: The aim of this study was to evaluate the rate and reason for refusal of telephone-based cardiopulmonary resuscitation (CPR) instruction by bystanders after the implementation of the dispatch center's systematic telephone CPR protocol. METHODS: Over a 15-month period the authors prospectively collected all case records from the emergency medical services (EMS) dispatch center when CPR had been proposed to the bystander calling in and recorded the reason for declining or not performing that the bystander spontaneously mentioned. All pediatric and adult traumatic and nontraumatic cases were included. Situations when resuscitation had been spontaneously initiated by bystanders were excluded. RESULTS: During the study period, dispatchers proposed CPR on 264 occasions: 232 adult nontraumatic cases, 17 adult traumatic cases, and 15 pediatric (traumatic and nontraumatic) cases. The proposal was accepted in 163 cases (61.7%, 95% confidence interval [CI] = 54.6% to 66.5%), and CPR was eventually performed in 134 cases (51%, 95% CI = 43.2% to 55.3%). In 35 of the cases where resuscitation was not carried out, the condition of the patient or conditions at the scene made this decision medically appropriate. Of the remaining 95 cases, 55 were due to physical limitations of the caller, and 33 were due to emotional distress. CONCLUSIONS: The telephone CPR acceptance rate of 62% in this study is comparable to those of other similar studies. Because bystanders' physical condition is one of the keys to success, the rate may not improve as the population ages.