Resus today spring 2015 by Media Publishing Company

Volume 2 No. 1

Spring 2015

Resuscitation Today A Resource for all involved in the Teaching and Practice of Resuscitation Supported by CPRO

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In this issue Education - Effects of pre-training Evidence - Out of hospital cardiac arrest Equipment - The next generation in simulation technology

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Contents

Contents 5

Editors Comment

EDUCATION

EDUCATION NEWS

EVIDENCE

EVIDENCE NEWS

EQUIPMENT NEWS

Resuscitation Today This issue edited by: David Halliwell MSc Paramedic Flfl c/o Media Publishing Company Media House 48 High Street SWANLEY, Kent BR8 8BQ ADVERTISING & CIRCULATION: Media Publishing Company Media House, 48 High Street SWANLEY, Kent, BR8 8BQ Tel: 01322 660434 Fax: 01322 666539 E: info@mediapublishingcompany.com www.MediaPublishingCompany.com PUBLISHED BI-ANNUALLY: Spring and Autumn

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Quality, innovation and choice

i-gel® single use supraglottic airway from Intersurgical i-gel is the second generation supraglottic airway of choice in many hospitals in Europe and around the world. ®

Indicated for use in resuscitation in adults, i-gel® is easy and rapid to insert and is consistently reliable – in many cases, insertion can be achieved in less than five seconds1. The device incorporates a gastric channel for improved safety, an integral bite block to reduce the possibility of airway occlusion and a buccal cavity stabiliser to aid rapid insertion and eliminate the potential for rotation. Low post-operative complications and high seal pressures provide benefits to both clinician and patient2. A number of case reports and clinical studies have highlighted the potential advantages i-gel® offers in the resuscitation scenario3,4,5,6, where seconds can make all the difference. The most recent addition to the i-gel range is the i-gel O2 Resus Pack. The i-gel O2 has been specially designed to facilitate ventilation as part of standard resuscitation protocols, such as those designated by the European Resuscitation Council (ERC). However, the i-gel® O2 also incorporates a supplementary oxygen port for the delivery of passive oxygenation, or Passive Airway Management (PAMTM), as part of an appropriate Cardio Cerebral Resuscitation (CCR) protocol. ®

You can find more information about the Intersurgical i-gel® range at: www.igel.com or http://www.intersurgical.com/products/airway-management/igel-supraglottic-airway Choose Intersurgical for Quality, Innovation and Choice. Contact information: Intersurgical, Crane House, Molly Millars Lane, Wokingham, Berkshire, RG41 2RZ, England. Tel: +44 (0)118 9656 300 Fax: +44 (0)118 9656 356 Email: info@intersurgical.com Website: www.intersurgical.com References: Bamgbade OA, Macnab WR, Khalaf WM: Evaluation of the i-gel airway in 300 patients. Eur J Anaesthesiol. 2008 Oct;25(10):865-6.

Richez B, Saltel L, Banchereau F, Torrielli, Cros AM: A new single use supraglottic airway with a noninflatable cuff and an esophageal vent: An observational study of the i-gel: Anesth Analg. 2008 Apr;106(4):1137-9.

Gatward JJ, Thomas MJC, Nolan JP, Cook TM: Effect of chest compressions on the time taken to insert airway devices in a manikin: Br J Anaesth. 2008 Mar;100(3):351-6

PUBLISHERS STATEMENT: The views and opinions expressed in this issue are not necessarily those of the Publisher, the Editors or Media Publishing Company. Next Issue Autumn 2015 Subscription Information – Spring 2015 Resuscitation Today is a bi-annual publication published in the months of March and September. The subscription rates are as follows:UK: Individuals - £12.00 inc. postage Commercial Organisations - £30.00 inc. postage Rest of the World: Individuals - £60.00 inc. postage Commercial Organisations - £72.00 inc. postage We are also able to process your subscriptions via most major credit cards. Please ask for details. Cheques should be made payable to MEDIA PUBLISHING. Designed in the UK by Hansell Design

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cover story

Gabbott DA, Beringer R: The i-gel supraglottic airway: A potential role for resuscitation?: Resuscitation. 2007 Apr;73(1):161-2.

Soar J: The i-gel supraglottic airway and resuscitation - some initial thoughts: Resuscitation. 2007 Jul;74(1):197.

UK Resuscitation Council Advanced Life Support Guide (5th Edition). Revised June 2008.

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Editors Comment The last few months have seen all of us in the Resuscitation world beginning to prepare for the forthcoming 2015 guidelines, I have been keeping a close eye on the pre publication releases and following the global leaders on Twitter! For many of us Twitter increases our exposure to new clinical advances, and often papers are published on Twitter many months before they see official journal review. Free Online Access Medical Education also continues to grow in popularity, with many now choosing to make their papers Open Access which is a fabulous way of reaching wider audiences.

â&#x20AC;&#x153;We are seeing a substantial growth in telemedicine and some of the telemedicine based resuscitation crash carts in the USA were drawing great crowds, with remote monitoring and leading of cardiac arrest teams - from afar - with all data and video fed into the crash cart.â&#x20AC;?

As usual this journal focusses on 3 main areas, Education, Equipment and Evidence and again we have some papers that are written specifically for this resuscitation journal, we also review some of the more interesting releases in the wider resuscitation press. Twitter continues to produce some great debates and those of you reading twitter will no doubt be very aware of forthcoming developments and successes in resuscitation worldwide. Many successes of individual cardiac arrests and clinicians are posted and new developments / observations are publicised here before ever seeing their presentation at conferences. In the last few months I have been fortunate to have attended a few global Resuscitation and Simulation events, Including the ASPIH conference - in Nottingham which was amazing for those involved in simulation and education. I also travelled over to NEW Orleans to the SSIH conference - again leading simulation experts from around the world presenting their new ideas and concepts. It was a privilege to learn from experts and to see some of the more cutting edge developments in use. We are seeing a substantial growth in telemedicine and some of the telemedicine based resuscitation crash carts in the USA were drawing great crowds, with remote monitoring and leading of cardiac arrest teams - from afar - with all data and video fed into the crash cart. We hope to have a review of telemedicine in Resuscitation in our next edition. Usually before the release of new guidelines there is a lull, but this year we have seen new manikin manufacturers entering the market, and the challenges to our traditional simulation strategies continue with the development of new platforms and ways of using technology to the benefit of students. February saw the Society in Europe for Simulation Applied to Medicine SESAM conference taking place in conjunction with Clinical Simulation Conference 2015 in Dubai - with further new products and concepts being released for the Global Simulation world. A review will follow in Our Summer Edition. We also have the Social Media and Critical Care - SMACC conference in June in Chicago with 2500 delegates from around the globe. This is an incredible conference which continues to double in size each year. New Conferences are being proposed within the UK for this year, with the team at ATACC and Lifeconnections joining up in the UK, and their Resuscitation Conference is already starting to fill. Links to other workshops and conferences can be found within this edition.

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Editors comment

David Halliwell MSc Paramedic FIfL

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EDUCATION

Effects of pre-training using serious game technology on CPR performance – an exploratory quasi-experimental transfer study Johan Creutzfeldt1,2*, Leif Hedman1,3 and Li Felländer-Tsai1,2 1 Department of Clinical Science, Intervention and Technology, Karolinska Institutet, K32, Stockholm, 141 86, Sweden; 2 Center for Advanced Medical Simulation and Training, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden; 3 Department of Psychology, Umeå University, Umeå, Sweden

Abstract Background Multiplayer virtual world (MVW) technology creates opportunities to practice medical procedures and team interactions using serious game software. This study aims to explore medical students’ retention of knowledge and skills as well as their proficiency gain after pre-training using a MVW with avatars for cardio-pulmonary resuscitation (CPR) team training. Methods Three groups of pre-clinical medical students, n=30, were assessed and further trained using a high fidelity full-scale medical simulator: Two groups were pre-trained 6 and 18 months before assessment. A reference control group consisting of matched peers had no MVW pre-training. The groups consisted of 8, 12 and 10 subjects, respectively. The session started and ended with assessment scenarios, with 3 training scenarios in between. All scenarios were video-recorded for analysis of CPR performance. Results The 6 months group displayed greater CPR-related knowledge than the control group, 93 (±11)% compared to 65 (±28)% (p<0.05), the 18 months group scored in between (73 (±23)%).

Conclusions This study supports the beneficial effects of MVW-CPR team training with avatars as a method for pre-training, or repetitive training, on CPRskills among medical students. Keywords: Assessment; Avatars; Cardiopulmonary resuscitation; Educational technology; e-learning; MVW; Virtual learning environments; Patient simulation; Students; Young adults

A major bottleneck for better outcome after cardiac arrest is the availability of trained layman rescuers. In Sweden 68% of witnessed out-of-hospital victims suffering sudden cardiac arrest are exposed to cardiopulmonary resuscitation (CPR) attempts by laymen rescuers [1,2]. In the US, the corresponding number is 44%, but with large variations between different areas [3]. Currently CPR training normally rests on a traditional model consisting of a theoretical introduction and individual manikin based procedural training. Although this type of training has evolved to the current state over the years, essentially the model itself has been unchanged. Also, in the current CPR guidelines, teamwork issues have impacted the recommendations [4-7], although clarifications of what characterizes effective teamwork during CPR are lacking [8]. With increasing computer literacy the use of computer gaming technology for learning and training, i.e. serious games, has been reported in several areas including medicine [9-17]. Theoretical benefits with this technology include the availability in remote settings and at free hours, but also inherent positive properties of the computer game technology in itself, e.g. the opportunity to tailor it to certain contextual demands and a property to match peoples’ level of knowledge and skills. Further, this technology enables experiential learning often with ample feed-back, creates a high level of engagement among participants, and carries the ability to switch context in order to support transfer [18-20]. By using multiplayer virtual world (MVW) technology with avatars it is possible to interactively practice situations involving several subjects. Although some positive results exist [21-23], to date there is a lack of knowledge on how effective serious games are in different training situations. Also, in general, it is believed that the effectiveness of training is dependent on many other factors than which modality is being used [24,25]. We have previously developed a MVW-CPR team training model (a serious game using avatars) and reported of its use among medical students. In a test-retest study we found that this training was feasible, popular and increased the subjects’ concentration as well as self-efficacy beliefs indicating that the participants experienced a higher level of preparedness [26]. Similar results were also seen in an international study on high-school students [27]. The aim of the current study was to explore if medical students pre-trained with MVW-CPR in teams had retained knowledge and skills and were able to transfer their proficiency gain to a full-scale simulator environment. Signs of transfer would support the value of using MVW technology for training CPR. Our main hypothesis was that subjects who had pre-trained using MVW would perform CPR faster and better in line with the guidelines. We also hypothesized that signs of retention would be greater proximal to training, and that retention would be greater for knowledge and skills that were actively trained as opposed to just lectured [28].

RESUSCITATION Today - SPRING 2015

At start the pre-trained groups adhered better to guidelines than the control group; mean violations 0.2 (±0.5), 1.5 (±1.0) and 4.5 (±1.0) for the 6 months, 18 months and control group respectively. Likewise, in the 6 months group no chest compression cycles were delivered at incorrect frequencies whereas 54 (±44)% in the control group (p<0.05) and 44 (±49)% in 18 months group where incorrectly paced; differences that disappeared during training.

Background

EDUCATION Methods Recruitment and sample This study was designed as an exploratory quasi-experimental controlled study with 3 groups: Two groups had attended MVWCPR training, 18 and 6 months respectively, before the study (18 m and 6 m), and one group served as reference group (control). The latter group was matched to the other groups, consisting of peers attending the same semester of medical school. Thirty-six medical students at Karolinska Institutet volunteered to participate during their preclinical period (second and third year). All of them had attended a compulsory conventional manikin based CPR training course during their first semester of medical school. Subjects were enrolled by announcements. The study was approved by the regional ethics committee at Karolinska Institutet, and informed consent was obtained from the participants. MVW-CPR team training The first phase of the study consisted of MVW-CPR team training. The training comprised two sessions. The first session started with a 10 minute rehearsal lecture on basic life support (BLS), followed by an approximately 20 minute long familiarization to the virtual environment. During this the participants learned how to control the avatar using the keyboard, communicate with each other using a headset with microphone, and performing various tasks. The actual team MVW-CPR training consisted of 4 short (4-5 minutes) scenarios. In these the subjects in groups of 3 had to take care of a cardiac arrest victim that collapsed in front of them. This involved approaching the victim, examining the victim and starting resuscitation as stated by the guidelines. The latter included an emergency phone call to the 911 dispatcher. The actions had to be performed in collaboration within the group. Following each scenario a brief (3-5 minute) feed-back session followed. Standard personal computers were used which were connected to the virtual world by broad band internet connections. After 6 months the subjects attended a similar session without the lecture.

Before assessment of CPR skills the subjects were presented with a short (approx. 10 min) standardized lecture on BLS, including bystander-CPR in order to give a common theoretical base. Also a 5 minute familiarization to the SimMan® full-scale simulator (Laerdal Medical) and the environment (in particular how to call for help), was included. The subjects were assessed and trained in teams of 2 or 3 rescuers. The first scenario was an assessment scenario. It was followed by a 20 minute standardized lecture on effective teamwork introducing the participants to so called Crew Resource Management (CRM) principles [29]. Thereafter training scenarios ensued during which two teams took turns in performing and observing. All over each team trained in 3 scenarios. In two of the training scenarios start of CPR was expected as required by the guidelines. In the third training scenario start of CPR was contra-indicated. The fifth and last scenario was again an assessment scenario. Figure 1 summarizes the design of the study.

RESUSCITATION Today - SPRING 2015

Loss of subjects All subjects from previous MVW-CPR training agreed to participate, but due to personal competing interests some subjects could not attend during the short time frame the study had to be carried out in. In the 18 months group 4 out of 12 subjects were lost and in the control-group 2 subjects were lost due to scheduling difficulties before the start of this study. No subjects dropped out during the study in any group. Background data is shown in Table 1. Table 1 Demographic data Subjects’ Characteristics Female / Male Age

Assessments and further training At start a pre-test on knowledge of basic life support was given. A posttest was performed after training. The knowledge tests consisted of 10 true/false statements. Two versions of the test existed in order to let each subject have different versions before and after training (Additional file 1- Knowledge quiz (A and B) at end of paper). Half of the subjects in each group started with one version, the rest with the other, after training this was reversed. Three or 6 items (depending on version) were directly related to bystander-CPR. Scores on the test were between 0-10, scores on CPR specific part were graded between 0-100 percent correct.

18 months 6 months Control group group group (n=8) (n=12) (n=10) 3 F / 5 M

6 F / 6 M

5F/5M

25.5 (± 3.9)

22.8 (± 2.6)

22.9 (± 2.0) Figure 1. Design of the study

EDUCATION During the scenarios the teams had to assess and resuscitate a victim by following the bystander-CPR guidelines (2005 version) [30]. At approximately 7 minutes after the yell for help the scenario was ended by help of a paramedic arriving at the scene, taking over responsibilities. After each scenario feed-back was given by an instructor and, when present, by observers. The feed-back focused on the CPR guidelines as well as on aspects of teamwork. Analysis and statistical methods All scenarios were video-taped for later analysis of CPR performance. This analysis was performed by a trained blinded assessor. Several measurements of performance were used: On group level time between the rescuers entering the room until start of chest compressions was calculated and no-flow time was determined. This was calculated as the total time that elapsed between the cycles of chest compression divided by the number of cycles performed minus 1. Furthermore adherence to the CPR guidelines was scored (provided as Additional file 2). On individual level the frequency of chest compressions was calculated. Friedman repeated measures analysis of variance on ranks was used for time dependent nonparametric data. Statistical comparisons, before-after, were made by use of the Wilcoxon signed rank test. Comparisons between groups were made by ANOVA on ranks with pairwise comparisons using Dunn’s method. The test on CPR-specific knowledge was performed as a post-hoc analysis. For nominal data Chi square test was used. The significance level was set at P<0.05. As P values are not adjusted for multiple testing, they have to be considered as descriptive. The calculations were performed using SigmaStat version 3.5 (Systat Software Inc, Point Richmond, CA, USA). Data are presented as mean [±SD]. Adult basic life support – Cardiopulmonary resuscitation

Results Knowledge Table 2 describes the test scores for all groups before and after training. Total test values are presented as absolute numbers, whereas the scores on CPR-specific questions are presented as % since the two versions contained different numbers of these.

The change of overall knowledge and CPR-specific knowledge in the entire study group changed from 7.1 (±1.5) to 8.3 (±0.9) (p<0.001) and 78% (±24%) to 95% (±10%) (p<0.001), respectively.

Performance Time from subjects entering the room until start of chest compressions did not differ between groups (during first scenario: 18 months group 23 (±11) seconds, 6 months group 21 (±7) seconds and control group 24 (±13) seconds respectively) or change significantly over time. The no-flow time (time after start of CPR, where no chest compressions were administered) did not differ significantly between groups (during first scenario: 18 months group 7.9 (±2.0) seconds, 6 months group 9.4 (±2.5) seconds and control group 7.8 (±1.4) respectively, during the last scenario: 18 months group 7.5 (±0.8) seconds, 6 months group 6.8 (±1.0) and control group 6.9 (±1.8) seconds respectively). During video analysis it was evident that this variable was rather complex; if for example only one rescue breath was given, or if they were given to rapidly the no-flow time would be shorter, but at the same time the guidelines were violated.

* European guidelines † Rescue breaths and chest compressions thereafter alternately continue until help arrives. According to 2005 ILCOR CPR guidelines published in 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 2: Adult basiclife support. Resuscitation 2005; 67(2-3):187-201.

Assessment of compliance to guidelines: A violation occurs every time the steps do not occur in correct order. This may involve additions, omissions or incorrect order. Furthermore a violation also occurs if the wrong number of chest compressions or rescue breaths occurs.

Figure 2. Mean number of violations to the bystander CPR guidelines in each scenario where CPR was performed.

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There was a clear difference in the first scenario regarding adherence to the CPR guidelines (Figure 2). This included performing the actions in a nonprescribed order, excluding diagnostic steps, stopping to check for pulses and not performing 30:2 cycles stated by the CPR guidelines.

EDUCATION This difference was not detectable during any of the following scenarios. We also noticed a tendency for less compliance with the guidelines during the last scenario for all groups. There was also a significant difference in the number of chest compression cycles that did not agree with frequencies stipulated by the CPR guidelines during the first scenario. In the 18 months group 44 (±49)% of the compression cycles occurred at frequencies of less than 80 /min or more than 125 /min. For the 6 months and control group these values were 0% and 54 (±44)% respectively. The difference between the control group and the 6 months group was statistically significant (p<0.001), as was the difference between the 18 months group and the 6 months group (p<0.001). Overall, as training progressed, there was a tendency towards increased compression rates. Also, in general, the large variation of frequencies seen in the 18 months group and the control group decreased. In particular in the 6 months group the increase over time of the compression frequency led to a large proportion of cycles with frequencies over 125 /min. In the last scenario there was significantly less incorrectly paced cycles in the control group compared to the 6 months group (Figure 3).

Evidently, the rationale for CPR training is preparing potential rescuers to actually perform CPR in real life. In this respect theoretical knowledge is useful only if applied correctly. It can be argued that theoretical and correctly applied knowledge are connected [24]. Better knowledge in theory supports correct action and might provide a scaffold for future learning. Factual knowledge may also provide basis for efficacy beliefs and create a more complete mental model of the phenomenon to promote retention of procedural knowledge.

Time before start of CPR During real-world CPR, time is a factor of crucial importance and was consequently recorded. As shown by the large variation, in this standardized setting, this parameter was difficult to draw any conclusions from. When assessing the recordings of the scenarios for performance, we also noted a large variation in competitiveness and acting amongst the participants which in turn might have concealed actual differences in how effective the initiation of CPR was.

Adherence to CPR guidelines Although, due to the small sample size in this exploratory study, statistical methods have not been used on this data, support for pre-training was found in how well the CPR algorithm, stated by the bystander CPR guidelines, was followed. Virtual world pre-training reduced uncertainty and initiatives outside the defined algorithm. Interestingly, this clear pattern was found, despite the fact that all subjects just minutes earlier had attended a standardized, brief rehearsal lecture. As was hypothesized, this indicated that actual training – although carried out several months earlier in a virtual world – would still outweigh the benefits of the lecture. Hence, probably memory of subject knowledge alone is not the key to correct CPR performance.

Psychomotor issues Figure 3. Mean frequency during cycles of chest compressions are displayed for each group in the separate scenarios.

Discussion

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In this exploratory study we found that medical students who in addition to conventional CPR training had participated in two sessions of virtual world CPR team training with avatars, performed better when assessed in full scale CPR simulation. In particular this was reflected by both better adherence to guidelines and more correct frequency of chest compressions. CPR knowledge Gaps in CPR related knowledge between the groups before training and in performance during the first scenario indicated that knowledge and behaviors trained in the virtual setting were retained to some degree in contrast to lectured knowledge where no retention could be detected. After having trained in 5 scenarios, the knowledge gap in CPR related knowledge was not detectable, and the performance gap in the last scenario had disappeared.

Among individual psychomotor performance measures, compression frequency and quality seem to be among the most important ones for real life positive outcome. During the first scenario there was a huge variation in frequency in the 18 months and control groups. Many of these subjects were outside the stipulated frequency range. After feed-back and recurrent training this variation was considerably smaller. Notably the subjects in the 6 months group were “right on spot”, but as training progressed, showed a drift towards too high rates. This may indicate that as training goes on the participants may get overly vigorous and that more focus might be needed on this phenomenon, alternatively support the use of technical or cognitive tools for correct psychomotor output keeping frequency of compressions correct [31-33]. Another important parameter is the “no-flow time” [34,35]. In this study it was defined as the time, after start of CPR, where no chest compressions were administered. Although calculated during all scenarios, this time did not change much during the training. The lowest no-flow time was recorded during scenarios where there were several quality issues, such as reduced quality in the rescue breaths. Therefore we did not further consider this data.

EDUCATION New CPR training methods have been developed and refined as reactions to several problems in conventional CPR training. In a previous study we argued that the administered MVW-CPR cannot stand alone as means of CPR training [26]. However, as indicated in this exploratory study, the use of MVW-CPR pre-training might be one way of preparing students for conventional CPR courses. This added training may serve as cognitive support for future training and real-world tasks, and is in line with other trends in medicine [36]. Possibly MVW-CPR team training can also be used for rehearsal after other modes of CPR training, although it has not been the focus for the current study. In this study the trainees are digital natives. Although CPR skills are important in many age groups, we believe that it would be easier to implement MVW-CPR team training in this group. The aged population, in which cardiac arrests most commonly occur, might also possibly benefit from such training, however from this study we can draw no such conclusions and results from such training may be much different than current results. For other digital native groups we expect that the positive effect of MVWCPR team training would be comparable. The strength of this study is its standardization regarding participants and protocol. CPR is often performed in groups [5]. Virtual world CPR team training with avatars has the advantage to address this issue. Although also assessments in this study to some extent were on group level, this introduced a weakness because group assessment carries the problem of decreasing statistical power. Further, the performance of groups is to some extent dependent on teamwork skills which can differ between different group constellations. One way of trying to reduce such influences was by adding a lecture on teamwork to the training program. Another limitation of this study is its small sample size. The study was conceived as a follow-up on subjects that had already received virtual CPR training. The limited sample was further reduced by loss of subjects. We therefore stress the exploratory nature of the study and must hence remember that the results have to be interpreted with caution. The validity of assessing CPR skills by use of full-scale simulators can also be questioned. To our knowledge no studies on this issue have been performed. On the other hand, this technique for training and assessment is already implemented for clinical training of skills and behaviours in various settings and scenarios [37].

Serious games for learning and training are receiving much attention. However, transfer of CPR skills trained in serious games is difficult to test in authentic CPR. Thus, this exploratory quasi-transfer study was designed to probe the potential future use for virtual worlds in emergency medicine.

Conclusions In this exploratory study we have demonstrated that conventionally trained medical students who in addition received multiplayer virtual world CPR

Abbreviations ANOVA: Analysis of variance; BLS: Basic life support; CPR: Cardiopulmonary resuscitation; CRM: Crew resource management; MVW: Multiplayer virtual world. Authors’ contribution JC assisted in technology development, helped conceive the study, participated in study design and served as subject matter expert (emergency medicine), acquired and analyzed data, took part in data interpretation as well as drafted the manuscript. LH contributed substantially to study design, served as subject matter expert (psychological assessment), interpreted data and critically revised the manuscript. LFT conceived the study and participated in study design as well as interpreted data and critically revised the manuscript. All authors read and approved the final manuscript. Acknowledgements We would like to express our gratitude towards Carl-Johan Wallin at the Center for Advanced Medical Simulation and Training for valuable contributions in design and planning of the study and Christopher Medin, Department of Biomedical Technology at Karolinska University Hospital for technical assistance and operation of equipment. We would also like to express our gratitude towards Emmy Nyqvist at the time of the study at Karolinska Institutet for video assessments. Further we thank Elisabeth Berg at the department of Learning, Informatics, Management and Ethics as well as Tony Qureshi at the department for Clinical Science, Intervention and Technology, both at Karolinska Institutet, for assistance with statistical methods. This study was fully financed by research grants from the Wallenberg Global Learning Network (WGLN), The Marianne and Marcus Wallenberg Foundation, Stockholm County Council and EU Research Programme Goal 1, Northern Sweden. References 1. Herlitz J: National Swedish registry for cardiac arrest – Yearly report of 2011. (in Swedish) Accessed 3 April 2012, at http://www.hlr.nu/sites/ hlr.nu/files/attachment/ Rapport%202011.pdf webcite 2. Nordberg P, Hollenberg J, Herlitz J, Rosenqvist M, Svensson L: Aspects on the increase in bystander CPR in Sweden and its association with outcome. Resuscitation 2009; 80(3): 329-333. 3. McNally B, Robb R, Mehta M, Vellano K, Valderrama AL, Yoon PW, Sasson C, Crouch A, Bray Perez A, Merritt R, et al.: Out-of- Hospital Cardiac Arrest Surveillance — Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010. In Morbidity and mortality weekly report. vol. 60th edition. Edited by Moolenaar RL, Casey CG, Rutledge TF. Atlanta, GA: Office of Surveillance, Epidemiology, and Laboratory Services, Center for Disease Control and Prevention, U.S. Department of Health and Human Services; 2011.

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A focus of this training study was to standardize the scenarios in order to evaluate how pre-training and subsequent full-scale training affected the participants. Full-scale simulator team training is costly and in very limited supply, and therefore cannot be seen as a realistic future alternative for larger groups in society. In this study, in the absence of real-world alternatives, full-scale simulation was mainly used as a way of creating a reasonably realistic way of assessing transfer.

team training in a serious game using avatars, showed better knowledge and performance when assessed in full scale CPR simulation. Better skills in terms of correctness were observed proximal to training. During repetitive training, already after a single scenario, these differences were greatly reduced demonstrating the steep proficiency gain of experiential learning compared to traditional lectures. The possibility to practice in a group setting during the virtual world training, as well as during scenario based full scale simulation addresses the need for group-focused training of CPR.

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EDUCATION 4. Edwards S, Siassakos D: Training teams and leaders to reduce resuscitation errors and improve patient outcome. Resuscitation 2012; 83(1): 13-15.

22. Hansen MM: Versatile, immersive, creative and dynamic virtual 3-D healthcare learning environments: a review of the literature. J Med Internet Res 2008; 10(3): e26.

5. Mancini ME, Soar J, Bhanji F, Billi JE, Dennett J, Finn J, Ma MH, Perkins GD, Rodgers DL, Hazinski MF, et al.: Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122(16 Suppl 2): S539-S581.

23. Heinrichs WL, Youngblood P, Harter PM, Dev P: Simulation for team training and assessment: case studies of online training with virtual worlds. World J Surg 2008; 32(2): 161-170.

6. Hunziker S, Johansson AC, Tschan F, Semmer NK, Rock L, Howell MD, Marsch S: Teamwork and leadership in cardiopulmonary resuscitation. J Am Coll Cardiol 2011; 57(24): 2381-2388. 7. Tschan F, Vetterli M, Semmer NK, Hunziker S, Marsch SC: Activities during interruptions in cardiopulmonary resuscitation: a simulator study. Resuscitation 2011; 82(11): 1419-1423. 8. Eikeland Husebø SI, Bjørshol CA, Rystedt H, Friberg F, Søreide E: A comparative study of defibrillation and cardiopulmonary resuscitation performance during simulated cardiac arrest in nursing student teams. Scand J Trauma Resusc Emerg Med 2012; 20:23. 9. Hew KF, Cheung WS: Use of three-dimensional (3D) immersive virtual worlds in K-12 and higher education settings: A review of the research. Brit J Educ Technol 2010; 41(1): 33-55. 10. Means B, Toyama Y, Murphy R, Bakia M, Jones K: Evaluation of evidence-based practices in online learning - a meta-analysis and review of online learning studies. Washington D.C: Center for Technology in Learning, U.S. Department of Education; 2010. 11. Peterson M: Computerized games and simulations in computerassisted language-learning: A meta-analysis of research. Simulat Gaming 2010; 41(1): 72-93. 12. Dickey MD: Three-dimensional virtual worlds and distance learning: two case studies of Active Worlds as a medium for distance learning. Brit J Educ Technol 2005; 36(3): 439-451. 13. Richardson A, Hazzard M, Challman SD, Morgenstein AM, Bruechner JK: A “Second Life” for gross anatomy: applications for multiuser virtual environments in teaching the anatomical sciences. Anat Sci Educ 2011; 4(1): 39-43. 14. Wiecha J, Heyden R, Sternthal E, Merialdi M: Learning in a virtual world: experience with using second life for medical education. J Med Internet Res 2010; 12(1): e1. 15. Knight JF, Carley S, Tregunna B, Jarvis S, Smithies R, de Freitas S, Dunwell I, Mackway-Jones K: Serious gaming technology in major incident triage training: A pragmatic controlled trial. Resuscitation 2010; 81(9): 1175-1179. 16. Mjelstad S, Halvorsrud R, Bach-Gansmo E: Field experiment with MATADOR – a system for net-based trauma team training. (in Norwegian) Scand J Trauma Resusc Emerg Med 2007; 15: 6-10. RESUSCITATION Today - SPRING 2015

17. Dev P, Heinrichs WL, Youngblood P: CliniSpace: a multiperson 3D online immersive training environment accesible through a browser. Stud Health Technol Inform 2011; 163: 173-179. 18. Oblinger DG: The next generation of educational engagement. J Interact Media in Educ 2004;, 8: Accessed 4 December 2012, at www-jime.open.ac.uk/article/2004-8-oblinger/199 webcite 19. Taekman JM, Shelley K: Virtual environments in healthcare: immersion, disruption, and flow. Int Anesthesiol Clin 2010; 48(3): 101-121. 20. Akl EA, Pretorius RW, Sackett K, Erdley WS, Bhoopathi PS, Alfarah Z, Schunemann HJ: The effect of educational games on medical students’ learning outcomes: a systematic review: BEME Guide No 14. Med Teach 2010; 32(1): 16-27. 21. Andreatta PB, Maslowski E, Petty S, Shim W, Marsh M, Hall T, Stern S, Frankel J: Virtual reality triage training provides a viable solution for disaster-preparedness. Acad Emerg Med 2010; 17(8): 870-876.

24. Bransford JD, Brown AL, Pellegrino JW, Anderson JR, Berliner D, Cooney MS, Eisenkraft A, Gelman R, Ginsburg HP, Glaser R, et al.: Learning: from speculation to science. In How people learn: brain, mind, experience, and school. Edited by Bransford JD, Brown AL, Cocking RR, Donovan MS, Pellegrino JW. Washington D.C: 25. McKendree J: e-Learning. In Understanding medical education: evidence, theory, and practice. Edited by Swanwick T. Chichester, West Sussex, UK: John Wiley & Sons; 2010:151-163. 26. Creutzfeldt J, Hedman L, Medin C, Heinrichs WL, Felländer-Tsai L: Exploring virtual worlds for scenario-based repeated team training of cardiopulmonary resuscitation in medical students. J Med Internet Res 2010; 12(3): e38 27. Creutzfeldt J, Hedman L, Youngblood P, Heinrichs WL, FelländerTsai L: Cardiopulmonary resuscitation training in high school using avatars in virtual worlds: Feasibility in a bi-national study. J Med Internet Res (in press) 28. Kaufman DM, Mann KV: Teaching and learning in medical education: how theory can inform practice. In Understanding medical education: evidence, theory, and practice. 1st edition. Edited by Swanwick T. Chichester, West Sussex, UK: WileyBlackwell; 2010:16-36. 29. Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH: Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992; 63(9): 763-770. 30. International Liaison Committee on Resuscitation: 2005 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 2: adult basic life support. Resuscitation 2005; 67(2-3): 187-201. 31. Abella BS, Edelson DP, Kim S, Retzer E, Myklebust H, Barry AM, O’Hearn N, Hoek TL, Becker LB: CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system. Resuscitation 2007; 73(1): 54-61. 32. Hostler D, Wang H, Parrish K, Platt TE, Guimond G: The effect of a voice assist manikin (VAM) system on CPR quality among pre hospital providers. Prehosp Emerg Care 2005; 9(1): 53-60. 33. Aramendi E, Ayala U, Irusta U, Alonso E, Eftestol T, KramerJohansen J: Suppression of the cardiopulmonary resuscitation artefacts using the instantaneous chest compression rate extracted from the thoracic impedance. Resuscitation 2012; 83(6): 692-698. 34. Hazinski MF, Nolan JP, Billi JE, Böttiger BW, Bossaert L, de Caen AR, Deakin CD, Drajer S, Eigel B, Hickey RW, et al.: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2010; 122(16 Suppl 2): S250-S581. 35. Christenson J, Andrusiek D, Everson-Stewart S, Kudenchuk P, Hostler D, Powell J, Callaway CW, Bishop D, Vaillancourt C, Davis D, et al.: Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation 2009; 120(13): 1241-1247. 36. Kahol K, Vankipuram M, Smith ML: Cognitive simulators for medical education and training. J Biomed Inform 2009; 42(4): 593-604. 37. Berkenstadt H, Ziv A, Gafni N, Sidi A: The validation process of incorporating simulation-based accreditation into the anesthesiology Israeli national board exams. Isr Med Assoc J 2006; 8(10): 728-733.

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EDUCATION NEWS Ensuring a cool recovery from cardiac arrest Researchers at Okayama University in collaboration with several medical centres in Japan have demonstrated the safety and efficacy of a hypothermal treatment – pharyngeal cooling – for cardiac arrest patients. Cooling the brain is known to prevent neurological problems in patients recovering from cardiac arrest. However most of the current methods for therapeutic hypothermia may not be initiated before return of spontaneous circulation. Researchers at Okayama University investigated a method for cooling the area at the top of the throat – the pharynx - because the arteries that supply the head with oxygenated blood run nearby. Cooling this area should be a good approach to cooling the brain but so far there have been no complete studies to determine whether pharyngeal cooling could be administered effectively or whether it may lead to other adverse side effects. The researchers alongside people working in emergency and critical care clinics set up a trial for 108 cardiac arrest patients. The medical staff administered treatments with or without pharyngeal cooling to patients at random, and subsequently recorded success rates of resuscitation and physiological conditions, including temperature both at the body core and in the head near the ear (tympanic temperature), mechanical or temperature damage to the pharynx, inflammation and blood platelet levels.

Background Hypothermia treatments and limitations Previous clinical data has indicated that quickly achieving therapeutic hypothermia is one of the most important factors for improving neurological outcomes for cardiac arrest patients. Approaches to achieving therapeutic hypothermia include intravenous infusion of cold fluid, which can increase re-arrest rates, and nasal cooling which is prone to cause extreme

Pharyngeal cooling method Pharyngeal cooling was begun during chest compression as soon as patients entered the emergency room or on return of spontaneous circulation (ROSC) if ROSC returned before entering the emergency room. In the current study pharyngeal cooling was administered using a pharyngeal cuff, a vinyl chloride tubular structure fitted into the upper oesophagus and pharynx. Saline solution at a temperature of 5°C was perfused into the cuff at a rate of 500 ml min−1 and pressure of 50 cm H2O. The temperature was chosen to be above freezing so that ice did not form, and treatment duration was also limited to 2 hours to avoid damage from the cold. The pressure was chosen to be below 60 cm H2O to avoid neuropathy – nerve damage – which has been reported with the use of equipment similar to the cuff. Low mechanical damage to the pharynx was thought to be largely due to similarities between the cuff and other medical instruments, as clinicians administering the treatment were familiar with using similar equipment. Choice of patients Patients aged 14-89 years old were considered eligible for the study within 15 minutes of collapse if they had suffered cardiogenic cardiac arrest or had been resuscitated from noncardiogenic arrest by medical personnel. A shortage of human resources meant that not all eligible patients were used in the study. Of the 818 patients that met the criteria, 113 were enrolled on the study. The researchers believe that the relatively small size of the fraction of eligible patients that were enrolled does not affect the quality of the study data because the random selection for treatment with or without pharyngeal cooling was undertaken after enrolment, and exclusion from the study after enrolment was very low. Inflammation and blood clotting disorders post cardiac arrest Systemic Inflammatory Response Syndrome (SIRS) has been highlighted as an important factor linked to illnesses following cardiac arrest that include brain and heart injury and restricted blood supplies to tissue. Poor blood clotting (coagulopathy) is observed with whole body cooling and severe brain damage and low levels of platelets (thrombocytopaenia) can impair blood clotting.

Incidences of all three diseases were diminished in patients treated with pharyngeal cooling: SIRS incidences in the pharyngeal cooling group amounted to 31% of patients compared with 57% in the control, coagulopathy incidences were lower in the first three days and thrombocytopaenia incidences dropped to zero compared with 17% of the control group Reference Yoshimasa Takeda, Takahisa Kawashima, Kazuya Kiyota, Shigeto Oda,Naoki Morimoto, Hitoshi Kobata, Hisashi Isobe, Mitsuru Honda, Satoshi Fujimi, Jun Onda, Seishi I, Tetsuya Sakamoto, Masami Ishikawa, Hiroshi Nakano, Daikai Sadamitsu, Masanobu Kishikawa, Kosaku Kinoshita, Tomoharu Yokoyama, Masahiro Harada, Michio Kitaura, Kiyoshi Ichihara, Hiroshi Hashimoto Beng, Hidekazu Tsuji Beng, Takashi Yorifuji, Osamu Nagano, Hiroshi Katayama,Yoshihito Ujike and Kiyoshi Morita, “Feasibility study of immediate pharyngeal cooling initiation in cardiacarrest patients after arrival at the emergency room”

Facilitation: the practical approach by ALSG The Advanced Life Support Group is pleased to be attending Life Connections 2015. Now in our 21st year as an international medical education charity dedicated to saving life by providing training, we are hosting a conference plenary on the eagerly awaited ILCOR update. We are also delighted to be able to offer a course on day one of the conference on Facilitation: the practical approach. All conference delegates interested in learning about or improving their role play and simulation facilitation skills would be welcome to apply for a place on this one day course. Prior to attending the course delegates will be required to complete a series of e-modules on our Virtual Learning Environment. During the day you will build on your understanding of group dynamics, feedback and running role plays and simulations and will have the opportunity to practise the elements essential to successful small group facilitation. Places are limited to 16 so please book now at http://www.lifeconnections.uk.com/conferencedetails/ We look forward to welcoming you at Life Connections and wish you an enjoyable conference experience.

RESUSCITATION Today - SPRING 2015

The results of the trial indicated effective cooling of tympanic temperatures, with no observed adverse side effects. In addition, incidences of inflammation and blood-clotting disorders were reduced in patients receiving pharyngeal cooling. As the researchers report, “In conclusion, it appears that the initiation of pharyngeal cooling is safe and feasible before and shortly after recovery of spontaneous circulation in the emergency room.”

nosebleeds (epistaxis) and accumulation of air in soft tissues (peri-orbital emphysema).

DE-CODING THE FUTURE OF ANAESTHESIA TRAUMA AND CRITICAL CARE 21 / 1 0 / 1 5 – 22 / 1 0 / 1 5 LIF E CONNE CTIONS 2 0 1 5 K E T T E R I NG CON F E R E N CE CE N TR E

For more information or to book your place for this event please visit: www.lifeconnections.uk.com or call 01322 660 434 www.atacc.co.uk

www.atacc.co.uk

ATACC De-coding The Future Embrace the words & wisdom of some of the greatest modern minds in healthcare. “ Why are resuscitationists & crit care doctors doing the same resuscitation as the skin doctors? “ Scott Weingart, 2014

“ I believe we have a responsibility to stay at the cutting edge of resuscitation, and I want to share what I learn.“ Cliff Reid, Sydney HEMS

“ The first principle of Leadership is Excellence. The most important thing for an educational leader is that they are clinically credible. Prof Simon Carley

“ Why repair when we could regenerate - We’re developing a material that has the right porosity and architecture to form new tissue.” Prof Kevin Shakesheff

Date: 21 – 22 October 2015 Place: Kettering Conference Centre Price : £250.00

Over the two days of this conference the ATACC Faculty will take us on a journey from the present day to somewhere around 10 years into the future. Carefully selected for their knowledge and also their ability to present in a passionate and inspirational style, these are the doctors, scientists and specialists who are creating the future today. Gareth Davies, Mark Wilson, Prof Simon Carley, Mike Tipton, James Tooley, Prof Mike McNicholas and Paul Trafford from the UK will join Raed Arafat, Ian Dunbar, SAMU, Sydney HEMS and ATACC from across the globe will create one of the greatest Faculties to gather in the UK within these fields of emergency care and recovery. Inspired by the recent RAGE Podcasts of Weingart, Swami and others the conference will open with an incredible session that takes a fresh look at resuscitation in terms of aggressive management, neuro-protection, re-animation and recovery with the overall aim of greatly improving the current dreadfully poor outcomes from cardiac arrest. Sessions will then move through the new technology that is going to potentially radically change our trauma & critical care practice. Some exists now and has been slow to get widely adopted, whilst other devices and therapies have barely left the lab yet.

The pace will be fast and dynamic, moving across a diverse and exciting range of topics such as Lodox scanning, new vehicle technology & essential changes in extrication, the next generation of heamostatics, 21st century tele-medicine, xenon anaesthesia. Education has always played huge part in ATACC and we have always strived to adopt and develop the very latest educational technology, such as our ProMedSim immersive simulator. Prof Carley will tell us where we go next and how we might get there best prepared. After the initial management of trauma we are left to recover and rehabilitate, but as we move forward we will look at the very latest in ‘bionic’ style aids and 3D-printing. But that is only the start as we then move into the world of stem cell, tissue regrowth and regenerative medicine. If this session doesn’t truly astound you then nothing will. The whole conference will be delivered and presented in a fresh and unique style, which hopes to capture the passion of the speakers, the delegates and the ATACC Faculty. Come and join us as we decode the future of trauma, resuscitation and critical care.

For more information or to book your place for this event please visit: www.lifeconnections.uk.com or call 01322 660 434

Date: 21 – 22 October 2015 Place: Kettering Conference Centre Price : £250.00

ATACC De-coding The Future Over the two days of this conference the ATACC Faculty will take us on a journey from the present day to somewhere around 10 years into the future. Carefully selected for their knowledge and also their ability to present in a passionate and inspirational style, these are the doctors, scientists and specialists who are creating the future today.

RESUSCITATION

TECHNOLOGY SESSIONS

RECONSTRUCTION

DECODING THE FUTURE THROUGH PHYSIOLOGY Prof Mike Tipton

IMAGING THE FUTURE Speaker to be confirmed Lodox

Professor of Human & Applied Physiology, Consultant in survival & thermal medicine RAF and UK Sport, Portsmouth, UK

BRAIN REHABILITATION – DOES COUNSELLING WORK? Surgeon Commander Prof Neil Greenburg

VETIGEL – STOPPING BLEEDING Mr Joe Landolina

Defence Professor of Mental Health, Royal Navy Institute of Psychiatry, King’s College London

GOOD SAM & CROWD SOURCING Mr Mark Wilson Neurosurgeon & Prehospital Emergency Medicine Physician, London HEMS, UK

SUSPENDED ANIMATION Dr Gareth Davies Prehospital Emergency Medicine Physician, Medical Director London HEMS, UK

ECMO IN THE STREETS – ‘THE REANIMATEUR’ Dr Lionel Lamhaut,

Biomedical Engineer, New York, US

TELE-MEDICINE THE NEXT STEP Dr Raed Arafat Prehospital Critical Care Physician. Secretary of State-Head of the Department of Emergency Situations at Ministry of Internal Affairs - Romania

INERT GASES & THE FUTURE OF ANAESTHESIA Dr James Toolley Paediatric Anaesthesia & Critical Care Retrieval Physician, UK

Anaesthesiologist and Prehospital Critical Care Physician, SAMU, Paris

PREVENTION

EDUCATION

VEHICLE DESIGN – WHEN WILL CASUALTY CARE CATCH UP? Mr Ian Dunbar

MEDUCATION AND BEYOND Professor Simon Carley St Emlyns

International Rescue Consultant, Holmatro, Netherlands

Professor of Emergency Medicine, Manchester, UK

CARS THAT WON’T LET YOU CRASH Dr Paul Trafford

SIMULATING THE FUTURE Dr Mark Forrest - ATACC

Anaesthetics and Intensive Care Consultant, Medical Advisor FIA Institute, Wirral, UK

Anaesthetics & Critical care Physician, Medical Director ATACC and Cheshire Fire & Rescue, UK

CREW COURSES – STAYING AHEAD Dr John Glasheen

Emergency Medicine and Prehospital Critical Care Retrieval Physician, Brisbane, Australia

MAKING 2 WHEELS SAFER Dr John Hinds Anaesthetics and Prehospital Critical Care Physician, Ireland

ROBOTICS Speaker to be confirmed BIOMECHATRONICS Speaker to be confirmed

TOP GUN – PRESIDENTIAL DEBATE SMURD - ROMANIA Dr Raed Arafat SYDNEY HEMS - AUSTRALIA Dr John Glasheen SAMU – FRANCE Dr Lionel Lamhaut HEMS - LONDON Dr Gareth Davies

REGENERATION STEM CELL-ORTHO Mr Sven Kili Senior Director, - Biosurgery and Cell Therapy & Regenerative Medicine at Sanofi, Oxford UK

3D PRINTING Speaker to be confirmed TISSUE REGENERATION Prof Kevin Shakesheff Professor of Regnerative Medicine, Nottingham

www.atacc.co.uk

EVIDENCE

Consensus Paper on Out-of-Hospital Cardiac Arrest in England Date: 16th October 2014 Revision Date: 16th October 2015

Introduction The purpose of this paper is to bring some clarity to the analysis of data associated with out-of-hospital cardiac arrest (OHCA) in England. This will help us to agree the scale of the problem, ensure that realistic targets for improvement can be set and the impact of interventions

Evidence-based interventions to improve rates from OHCA: Countries with the highest rates of OHCA survival are those which have strengthened all 4 links in the chain of survival:

assessed.

Incidence of OHCA in England In England in 2013 the Emergency Medical Services (EMS) attempted to resuscitate approximately 28,000 cases of OHCA.1 There are many more cases of OHCA where the EMS do not attempt resuscitation because on their arrival the EMS assess the victim to be beyond resuscitation. This is because the victim has been dead for several hours, or has suffered severe trauma which is not compatible with life, or because the opportunity to start resuscitation was not taken sooner while the EMS were on their way. If more bystanders had the confidence and skills to call 999 quickly, deliver effective cardiopulmonary resuscitation (CPR) until the EMS arrive, and when appropriate use a public access defibrillator, the number of cases where the EMS could attempt resuscitation would increase. Approximately 80% of OHCAs occur at home and 20% in public places.2 Only about 20% are in a “shockable rhythm” (i.e. treatable by defibrillation) by the time the EMS arrive.2 Survival is much more likely when a shockable rhythm is present.3 The proportion of people in shockable rhythm could be increased if more cardiac arrest victims received immediate and effective CPR from bystanders. Therefore more immediate 999 calls and immediate CPR given by bystanders could increase the number of people who receive CPR by the EMS. This will increase the number of people who are given a chance of surviving, and ultimately increase the number of people who

Survival rates from OHCA in England: The average overall survival to hospital discharge from 28,000 EMS treated OHCA in England is 8.6%.1 This is significantly lower than for populations in other developed countries: North Holland 21%5, Seattle

There is limited data on the current rate of bystander defibrillation with a public access defibrillator (PAD) following an OHCA. One study in the South of England reported bystander defibrillation in 1.74% of OHCA cases.8 When someone has a cardiac arrest, every minute without CPR and defibrillation reduces their chances of survival by 7-10 per cent.9,10,11 Rates of bystander CPR and PAD use in the UK are believed to be low for a number of reasons: • Failure to recognise cardiac arrest • Lack of knowledge of what to do • Fear of causing harm (such as breaking the victim’s ribs) or being harmed (acquiring infection from a stranger when giving rescue breaths) • Fear of being sued

20%6 and Norway 25%.3 Although these figures have to be interpreted

• Lack of knowledge of the location of PADs

with caution as there are some differences in the way that figures are

• No access to a PAD at the time of the cardiac arrest

presented, there is a clear potential to improve survival rates in the UK. Improving survival rates from OHCA is a major propriety for the

As the chain of survival illustrates, a person is most likely to survive an OHCA in the following circumstances:

Resuscitation Council (UK), the British Heart Foundation and the NHS England. This was identified by the Department of Health in the Cardiovascular Disease Outcomes Strategy (2013).

RESUSCITATION Today - SPRING 2015

do survive when they are given CPR.4

The current rate of initial bystander CPR in England is reported as being 43%7 (compared, for example to 73% in Stavanger, Norway during 2006-2008). However, this includes some situation where the bystander initiated CRP without having to be instructed to do so, as well as situations where the bystander initiated CPR following the instructions of the emergency medical dispatcher after calling 999. The latter situation may result in a delay of up to several minutes before the victim receives CPR. Such delays could be minimised if more members of the public were able and willing to recognise cardiac arrest and attempt CPR immediately.

• Their cardiac arrest is either witnessed by a bystander or the victim is discovered immediately after collapsing

EVIDENCE • The bystander calls 999 immediately • They bystander delivers effective CPR without delay • The cause of the cardiac arrest is a sudden disturbance of heart rhythm, which may be caused by a heart attack or may be due to another heart condition, sometimes an inherited heart condition

least until a defibrillator arrives (and often also immediately following defibrillation) if the person is to survive. This is true even in the case of in-hospital cardiac arrests where defibrillators are more often readily available. It should be noted that 80% of cardiac arrests occur at home where defibrillators are not usually available, but calling 999 immediately and delivering effective CPR at home can still save lives.

• The cardiac arrest is due to a “shockable” rhythm disturbance (ventricular fibrillation or ventricular tachycardia) • There is a PAD close by which another bystander can fetch

Q. If we had more defibrillators in public places would more people survive an OHCA?

• The bystander uses the PAD without delay

A. Public access defibrillators (PADs) are most likely to be used (and

• The EMS arrive very quickly (within minutes of being called)

used effectively) in places used or attended by large numbers of people. Cardiac arrest is more likely in some such places (for example large

Frequently asked questions Q. What is the total number of cardiac arrests in England? A. The total number of cardiac arrests in England is unknown. Before quoting any figure it is important to define what is meant by “cardiac arrest”. In everyone who dies (for example from advanced conditions such as cancer or the final stages of severe lung disease, heart disease or kidney disease) the heart will stop as part of the process of dying. Attempting to restart the heart with CPR would

railway stations and airports) than in others.14 It makes sense to ensure that all such places have PADs readily available. In other places where cardiac arrests may occur less frequently and be more widely spread out it makes sense to try to have enough PADs to allow rapid access to a nearby defibrillator for as many cardiac arrest victims as possible. Public access defibrillators are an important part in the chain of survival but they are not the only part. 80% of cardiac arrests occur at home, where defibrillators are not usually available, but calling 999 immediately and delivering effective CPR at home can still save lives. Defibrillation

provide no benefit in such situations.

with a PAD can save lives from OHCA when the cardiac arrest rhythm

A figure of 60,000 OHCAs per year in the UK is often quoted. This is

a “shockable” rhythm when the EMS arrive. This figure could be

probably derived from a report by the Ambulance Services Association12 which identified 57,345 OHCAs in 2006, of which 25,143 received attempted CPR by the EMS and 32,202 who did not. It is uncertain how many of those 32,202 people would have received CPR from the EMS if they had been called earlier and / or bystanders had given CPR

is “shockable”. Currently only 20% of cardiac arrest victims are in increased if more cardiac arrest victims received immediate, effective CPR from bystanders. Prompt access to a PAD may allow treatment of a shockable rhythm before the arrival of the EMS in situations where that opportunity would have been lost before their arrival.

whilst waiting for the EMS to arrive. The total figure of 60,000 is also

Q. Is hands-only CPR as good as full CPR that includes mouth-to-

compatible with the reported incidence of cardiac arrest in Europe of

mouth ventilation?

1/1000 of the population per year.

A. In a cardiac arrest, it is better for a bystander to do something The most important number to consider is the total number of cardiac

rather than nothing. Some people are untrained or unwilling to deliver

arrests from which the person may have a chance of surviving if someone

“rescue breaths” (mouth-to-mouth ventilation). If the bystander is

starts a resuscitation attempt immediately. This remains uncertain but is

trained and willing to deliver rescue breaths effectively as well as chest

likely to be greater than the number of cardiac arrests in which the EMS

compressions they should do so as this remains the recommended

currently attempt resuscitation (28,000 in England in 2013).

treatment. If not, it is better to deliver “hands-only CPR” (i.e. chest compressions) immediately and without interruption, rather than doing

Q. Why is it important to deliver CPR as well as defibrillation?

nothing or attempting “rescue breathing” ineffectively.

A. Each link in the chain of survival is important. Calling 999 RESUSCITATION Today - SPRING 2015

immediately ensures that emergency professional help is on the way as

Q. Would every cardiac victim survive if they had effective CPR

quickly as possible – the person is unlikely to survive without receiving

and defibrillation?

expert help as soon as possible at the scene, en route to hospital and after arrival.

A. No. The most common cause of a cardiac arrest is a “heart attack” (acute myocardial infarction). In that situation survival will not only

CPR increases the chances of surviving because it keeps some blood

depend on being resuscitated from rhythm disturbance causing the

circulation to vital organs such as the brain and the heart itself. It also

cardiac arrest, but also on the amount of heart muscle that has been

increases the likelihood of the heart remaining in a “shockable” rhythm

damaged by the heart attack, how quickly the person receives treatment

rather than deteriorating to a “non-shockable” rhythm (referred to in lay

for that and how well they respond to treatment.

terms as a “flat line”). This matters because a cardiac arrest victim is more likely to survive if their heart is in a “shockable” rhythm from which

Survival from a cardiac arrest is also dependent on the underlying state

it may be possible to shock them out of cardiac arrest with a defibrillator.

of health of the victim. If the person already has important medical

Given the random occurrence of cardiac arrest, it is relatively rare for

conditions (for example severe lung or heart disease or advanced

anyone to have a cardiac arrest right next to a defibrillator in a public

cancer) when they suffer a cardiac arrest, their chance of CPR leading

place. Delivering CPR promptly and effectively is therefore crucial, at

to survival will be much less than if their health had been good.

EVIDENCE Survival is also less likely in the event of major trauma and shock following blood loss caused by injury, for example in a road traffic accident.

10. Larsen MP, Eisenberg MS, Cummins RO et al. Predicting survival from out-of-hospital cardiac arrest: a graphic model. Ann Emerg Med 1993; 22:1652-8.

Q. How many public access defibrillators are in England?

11. Valenzuela TD, Roe DJ, Cretin S, Spaite DW, Larsen MP. Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model. Circulation. 1997; 63:3308-3313.

A. Nobody knows because there is no systematic arrangement in place to record the location of all PADs. In July 2014 the British Heart Foundation committed to fund the setting up of a national PAD database for use across the whole of the UK. However, this is only part of the solution. It is crucial to increase public awareness of: • Cardiac arrest • How to recognise it • The need to call 999 immediately • The need to start CPR immediately • The fact that PADs can be used safely by anyone If this happens we can expect more people to intervene quickly and effectively in the event of a cardiac arrest, resulting in more lives saved.

References 1. www.england.nhs.uk/statistics/statistical-work-areas/ambulancequality-indicators/ 2. London Ambulance Service Cardiac Arrest Annual Report 2012/2013 [www.londonambulance.nhs.uk] 3. Lindner TW,Soreide E, Nilsen OB, Torunn MW, Lossius HM. Good outcome in every fourth resuscitation attempt is achievable – An Utstein template report from the Stavanger region. Resuscitation 2011; 82:1508-13.

12. Ambulance Service Association. National Out-of-Hospital Cardiac Arrest Project 2006. 13. de Vreede-Swagemakers JJ, Gorgels AP, Dubois-Arbouw WI et al. Out-of-hospital cardiac arrest in the 1990s: a population based study in the Maastricht area on incidence, characteristics and survival. J Am Coll Cardiol 1997; 30:1500-1505. 14. Colquhoun M. National database of Automated External Defibrillator (AED) use. https://www.resus.org.uk/pages/Reports/Report-National_ database_of_AED_use.pdf.

Other relevant published papers: Murakami Y, Iwami T, Kitamura T, Nishiyama C, Nishiuchi T, Hayashi Y, Kawamura T and the Utstein Osaka Project. Outcomes of Outof-Hospital Cardiac Arrest by Public Location in the Public Access Defibrillation Era. JAMA 2014; doi: 10.1161/JAHA. 113.000533. Wissenberg M, Lippert FK, Folke F, Weeke P, Hansen CM, Christensen F, Jans H, Hansen PA, Lang-Jensen T, Olesen JB, Lindhardsen J, Fosbol EL, Nielsen SL, Gislason GH, Kober L, Torp-Pedersen C. Association of National Initiatives to Improve Cardiac Arrest Management With Rates of Bystander Intervention and Patient Survival After Out-Of-Hospital Cardiac Arrest. JAMA. 2013; 310(13):1377-1384. doi: 10.1001/ JAMA.2013.278483.

4. Waalewijn RA, Tijssen JGP, Koster RW. Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: results from the Amsterdam Resuscitation study (ARREST). Resuscitation 2001; 50:273-279.

6. Division of Medical Services Public Health – Seattle & King Country 2013 Annual Report to the King County Council. http://www.kingcountry.gov/healthservices/health/ems/reports.aspx. 7. Perkins GD. Data on file. OHCA database. 8. Deakin CD, Shewry E, Gray H, Public access defibrillation remains out of reach for most victims of out-of-hospital sudden cardiac arrest. Heart 2014; 100:619:623. 9. Holmberg M, Holmberg S, Herlitz J. Incidence, duration and survival of ventricular fibrillation in out-of-hospital cardiac arrest patients in Sweden. Resuscitation 2000; 44:7-17.

RESUSCITATION Today - SPRING 2015

5. Grasner JT, Herlitz J, Koster RW, Rosell-Ortiz F, Stamatakis L, Bossaert L. Quality management in resuscitation – towards a European cardiac arrest registry (EuReCa). Resuscitation 2011; 82:989-94.

LIFE CONNECTIONS 2015

CONNECTING LIFE SAVERS WITH ONE COMMON GOAL Diary Date: Wednesday 21st & Thursday 22nd October 2015 Kettering Conference Centre, Kettering, Northants NN15 6PB Life Connections 2015 will be taking place at the Kettering Conference Centre, Kettering, Northants, on October 21st and 22nd and, once again, has plenty to offer those wishing to keep up-to-date with new techniques and maintain their CPD portfolios, all at affordable delegate rates!!! For those taking advantage of our early bird 2 for 1 offer, Kettering has a wealth of reasonably priced accommodation but book early! Programmes to date are as follows:

WEDNESDAY 21ST OCTOBER

Resuscitation Conference taking place the following day (saving £36.00).

ALSG Facilitation Course - The Practical Approach. Those interested in learning about or

improving their role play and simulation facilitation skills are welcome to apply for a place on this one day course. Prior to attending the course delegates will be required to complete a series of e-modulars on the ALSG Virtual Learning Environment. Only 16 delegate places are available at £140. Early Bird Offer - Book by March 31st to also secure a FREE delegate place on our Resuscitation Conference taking place the following day (value £48).

ATACC Conference ATACC "Decoding the Future" - This ground-

Medipro Training - are running a Paediatric Workshop which will include a general approach to paediatrics such as 'Spotting a Sick Child', 'Red Flags Pre-Hospital', and 'Pre-Hospital Pain Management. Only 25 places are available at £60.00. Early Bird Offer - Book by March 31st to also secure a FREE delegate place on our Resuscitation Conference taking place the following day (value £48).

Inspired by SMACC, TEDmed and in typical innovative ATACC style this fast paced and stimulating conference is aimed at doctors, nurses and other healthcare professionals at the cutting edge of medicine. Join us in decoding the future of Trauma & Critical Care.

Jamie Todd of Pre-Hospital Care Consultancy Ltd is running a one day NAEMT

breaking 2 day course aims to explore the very latest medical advances in the fields of Resuscitation, Trauma, Anaesthesia & Critical Care. A truly breathtaking list of International experts will present both advanced current practice and also remarkable evolving research that we are likely to see adopted over the next 5-10 years.

Two day delegate rate £250, one day delegate rate (Wed or Thurs) £150.

Paramedic Practice Conference - Professor Sir Keith Porter, Patrick Bourke, Jamie Todd, Dr Simon Le Clerc and Mike Davis are among this year's speakers who will be giving presentations on a number of wide and varied topics such as: "The Importance of Non-Technical Skills in the Paramedic Community", "Intubation without traditional Laryngoscopy - Is this the Future?", "Shock May Hinder Bleeding - Cannon 1917. Have We Moved Forward?", "The Pre-Hospital Management of Traumatic Cardiac Arrest", etc that will capture delegate interest. Early Bird Offer Book by Mar 31st to secure a delegate rate of £36.00 (saving £12) or pay £60.00 to also attend the

Course ideal for First Responders, Fire Fighters and Police Officers. Only 16 places are available on this course offered at £108 (50% below normal course costs). Delegates will also receive a free NAEMT TFR Manual (worth £25) courtesy of Class Publishing. Early Bird Offer - Book by Mar 31st to also secure a FREE delegate place on our Resuscitation Conference taking place the following day (value £48).

Meditech Global are running a Motorsport Medicine CPD Workshop, aimed at medics and rescue personnel involved with motor sport events. The day will include Scene Safety, Airway Management and Appropriate Casualty Extrication. Speakers will include; FIA Doctors and active motor sport paramedics. Only 25 places are available at £72 per person. Early Bird Offer - Book by Mar 31st to also secure a FREE delegate place on our Resuscitation Conference taking place the following day (value £48).

All prices quoted are inclusive of VAT. To secure your 2 for 1 delegate place or to register for any of the above conferences/study days call the organisers office on 01322 660434

LIFE CONNECTIONS 2015

CONNECTING LIFE SAVERS WITH ONE COMMON GOAL MORE CHOICE, MORE VALUE, MORE CPD OPPORTUNITIES MORE 2 for 1 EARLY BIRD OFFERS THURSDAY 22ND OCTOBER ATACC Conference ATACC "Decoding the Future" - Day 2.

guides on Early Warning Scores, your skills in this area will be tested during the day using various ALS case studies and scenarios. Early Bird offer – Book by Mar st 31 to also secure a FREE delegate place on our Paramedic Conference taking place the previous day (value £48.00).

Resuscitation Today Conference speakers including Professor Sir Keith Porter, Jamie Todd and Mike Davis are amongst those who will all be providing up to the minute presentations on topics of great interest to Resuscitation Officers such as, Incorporating Non-Technical Skills in Life Support Teaching? The new Resus Guidelines will also be st announced, - Early bird offer – book by Mar 31 to secure a rate of £36 (saving £12) or pay £60 to also attend Wednesday's Paramedic Conference (saving £36).

Meditech Global are repeating their Motorsport Medicine CPD Workshop, aimed at medics and rescue personnel involved with motorsport events. The day will include Scene Safety, Airway Management and Appropriate Casualty Extrication. Speakers will include FIA doctors and active motorsport paramedics. Once again only 25 places are available at a rate of £72. st Early Bird offer – Book by Mar 31 to also secure a FREE delegate place on our Paramedic Conference taking place the previous day (value £48).

One day delegate rate £150.

Outreach Rescue Study Day - this organisation and the quality of their educational programmes need no introduction, next year's topics include "Key Principles of Patient Packaging under Varying Constraints" - only 20 places are available at a delegate rate of £72. Early Bird offer – Book by Mar st 31 to also secure a FREE delegate place on our Paramedic Conference taking place the previous day (value £48).

Jamie Todd of Pre-Hospital Care Consultancy Ltd, is running a one day Difficult Airway Course to

include Airway Algorithms, BVM & Laryngoscopy and EGDs and Rescue Airways, etc. Only 16 places are available at a delegate rate of £108 (50% below normal course costs). - Early Bird offer- book by Mar 31st to also secure a FREE delegate place on our Paramedic Conference taking place the previous day (value £48).

Medipro Training are running a one day Minor Injuries Workshop to include Musuloskeletal Assessment and Management of the Ankle, Knee, Shoulder, Wrist and Urinalysis Pre-Hospital. The workshop will include practical exercises. Only 25 places are available at a delegate rate of £60. Early bird offer - Book by Mar 31st to also secure a FREE delegate place on our Paramedic Conference taking place the previous day (value £48.00).

Thames Group are running a Cardiac Based Study Day on ECG Interpretation and have available 20 delegate places at £90. Alan R D Clarke MBE, Paramedic & Pre-Hospital Care Consultant, will be running an interactive workshop on the subject of Long QT Syndrome and other Cardiac Arhythmias, which should be of interest of anyone in the field of pre-hospital emergency care. Alan bases many of his sessions on the deteriorating patient and the national

Once finalised all Conference/Study Day Programmes can be viewed on

www.lifeconnections.uk.com

medical

EVIDENCE For this months reviews of resuscitation evidence we have used some

Olaussen A, et al.

of the latest papers from “life in the fast lane” this is one of the more influential blog sites used by the FOAM twitter community. Fraser K et al.

The Emotional and Cognitive Impact of Unexpected Simulated Patient Death A Randomized Controlled Trial

Return of consciousness during ongoing Cardiopulmonary Resuscitation: A systematic review Resuscitation 2014; 86: 44-48. PMID 25447435

Chest. 2014; 145(5): 958-63. PMID: 24158305

• After introduction of mechanical CPR device CPR induced

• What is the effect of simulation patient death on trainees?

• Though CPR induced consciousness may be distressing for the

consciousness seems more prevalent. • This study looks into the question and finds that medical students

rescuers (and maybe the patient) it is often percieved as a good

randomized to having their simulated patient die report increased

prognostic sign of outcome. The current guidelines on advanced

cognitive load and had poorer learning outcomes.

cardiopulmonary resuscitation focus on delivering high quality

• The authors caution that this doesn’t mean we shouldn’t have simulated patients die but that we need to plan for this outcome intelligently. • Recommended by: Anand Swaminathan Many of us running clinical ALS scenarios may deliberately run into the negative effects reported in this paper...

chest compressions with minimal interruptions only pausing for rhythm check or if the patient shows signs of life. Thus CPR induced consciousness may be mistanken for signs of life interupting the sequence of CPR and influence the quality of care. • This systematic review only identified reports on 10 patients. The incidence, implications and prognostic value of CPR-induced consciousness remains unknown and should be eveluated.

Calle PA et al.

Inaccurate treatment decisions of automated external defibrillators used by emergency medical services personnel: Incidence, cause and impact on outcome

Many anecdotes exist and again this fascinating area of research will increase it’s profile with the ongoing development of quality resuscitation. The ethical side of the mechanically CPR dependant patient will also be debated in future.

THE CAPABILITY OF PROFESSIONAL - AND LAY-RESCUERS TO ESTIMATE THE CHEST COMPRESSION-DEPTH TARGET: A SHORT, RANDOMIZED EXPERIMENT.

• This is an interesting and concerning paper.

Author: van Tulder R

• Two authors reviewed all rhythm analysis algorithm (RAA) from

Resuscitation, [Epub ahead of print]

patients who had an AED activated secondary to cardiac arrest. The authors found that in 16% of shockable rhythms (23 of 148) the AED

Editors comment - One of the latest resuscitation papers published

did not advise shock, often secondary to artefacts or “fine V-fib”.This

recently is summarised below it is a really interesting study as it

article shows a concerning incidence of “failure to defibrillate” among

suggests that estimation of depth is often poor by both professional

OHCA receiving AEDs.

and lay rescuers.

• Recommended by: Daniel Cabrera In CPR, sufficient compression depth is essential. The American As researchers in resuscitation many of us may have encountered

Heart Association (“at least 5cm”, AHA-R) and the European

anomalies with data accuracy and downloads, and this is definitely

Resuscitation Council (“at least 5cm, but not to exceed 6cm”,

an area requiring further attention.

ERC-R) recommendations differ, and both are hardly achieved.

RESUSCITATION Today - SPRING 2015

Resuscitation 2015. PMID: 25556589

• Recommended by: Søren Rudolph

EVIDENCE This study aims to investigate the effects of differing target depth instructions on compression depth performances of professional and lay-rescuers. 110 professional-rescuers and 110 lay-rescuers were randomized (1:1, 4 groups) to estimate the AHA-R or ERC-R on a paper sheet (given horizontal axis) using a pencil and to perform chest compressions according to AHA-R or ERC-R on a manikin. Distance estimation and compression depth were the outcome variables. Professional-rescuers estimated the distance according to AHA-R in 19/55 (34.5%) and to ERC-R in 20/55 (36.4%) cases (p=0.84). Professional-rescuers achieved correct compression depth according to AHA-R in 39/55 (70.9%) and to ERC-R in 36/55 (65.4%) cases (p=0.97). Lay-rescuers estimated the distance correctly according to AHA-R in 18/55 (32.7%) and to ERC-R in 20/55 (36.4%) cases (p=0.59). Lay-rescuers yielded correct compression depth according to AHA-R in 39/55 (70.9%) and to ERC-R in 26/55 (47.3%) cases (p=0.02). Professional and lay-rescuers have severe difficulties in correctly estimating distance on a sheet of paper. Professional-rescuers are able to yield AHA-R and ERC-R targets likewise. In lay-rescuers AHA-R was associated with significantly higher success rates. The inability to estimate distance could explain the failure to appropriately perform chest compressions. For teaching lay-rescuers, the AHA-R with no upper limit of compression depth might be preferable.

Workload during cardiopulmonary resuscitation Author: Küpper T 2015-02-01 Editors comments - this is a great study - although small it suggests that CPR using modern 2010 guidelines is slightly harder to perform than using guidelines of old. The use of telemetry and cycling based science RESUSCITATION Today - SPRING 2015

and the use of physiological testing to test human ability to perform CPR is a great area for others to explore. Suggesting that many cardiac arrest sufferers may themselves live with a rescuer with pre existing disease and therefore at risk of over exertion themselves is interesting... Lay resuscitation is crucial for the survival of the patients with out-ofhospital cardiac arrest. Therefore, lay CPR should be a basic skill for everyone. With the growing proportion of retired people in the Western societies, CPR performed by people with preexisting diseases and at risk of cardiac events is expected to grow. There is little knowledge about the workload during CPR and the minimum workload capacity of the rescuer. Pulse frequency, oxygen uptake, and CO2 elimination were measured by telemetry, while CPR was performed using a manikin with digital

equipment for the standardization of the procedure. The same parameters were measured during a standard exercise testing protocol (spiroergometry) on a bicycle to analyze the aerobic endurance range of the participants. Data from the resuscitation protocols were correlated with those from spiroergometry to establish a simple standard investigation procedure to check people at risk and to give minimum requirements to perform CPR in Watts/kg. The study consisted of two parts: 1 (n = 16) explored minimal workload cutoffs for the rescuer using the 1995 recommendations and 2 (n = 14) tested the latest 2010 guidelines to compare both recommendations. When tested according to the 1995 guidelines, heart frequency of rescuers increased from 83.0 bpm (±11.3) at rest to 109.9 bpm (±12.6; P = 0.0004). The newer 2010 guidelines increased the workload marginally more (n.s.). CPR can be performed by healthy people within the range of aerobic endurance. The minimal requirements for trainings are 1.6-1.8 W/ kg body weight in standard cycling ergometry. People at risk should be trained very careful. Since there is no significant lower workload when following the 1995 recommendations, people at risk should be trained according to the latest recommendations. In the case of a real resuscitation, such trained individuals must additionally take into account any symptoms. International archives of occupational and environmental health, 88(2):175-84. Epub 2014 May 30. PreMedline Identifier: 24874840

“Lay resuscitation is crucial for the survival of the patients with out-of-hospital cardiac arrest. Therefore, lay CPR should be a basic skill for everyone. With the growing proportion of retired people in the Western societies, CPR performed by people with preexisting diseases and at risk of cardiac events is expected to grow. There is little knowledge about the workload during CPR and the minimum workload capacity of the rescuer.”

EVIDENCE NEWS Computed tomography findings “Hybrid” clinician-managers are of complications resulting from crucial to NHS improvement, cardiopulmonary resuscitation says research But Oxford academic warns that they need Yuta Kashiwagi, Tomoki Sasakawa, Akihito Tampo, more support if change is to be Daisuke Kawata, Takeshi Nishiura, Naohiro Kokita, implemented effectively Hiroshi Iwasaki, Satoshi Fujita Introduction

If they take on a management role, they often see it as something of a sideline – either they have been asked to “take a turn” (defined by Fitzgerald and her colleagues as passive professional obligation), or they feel that they need to “protect” the profession from encroaching managerialism (reactive professional obligation).

Saïd Business School, University of Oxford “These ‘incidental’ hybrid managers

This retrospective study was conducted to evaluate injuries related to cardiopulmonary

Service improvements and organisational

typically use their roles to keep medical

resuscitation (CPR) and their associated

change in the NHS are more effective

professional work separate from the

when led by clinicians with management

demands of politics and management

responsibilities than by full-time managers,

and to protect it from change,” explains

after successful resuscitation.

according to research by Professor Louise

Fitzgerald. “They are not really interested

Fitzgerald, Saïd Business School, University

in service improvement, seeing it as a ‘box-

Methods

of Oxford. But these “hybrid” managers are

ticking’ exercise. To effect real change, the

currently struggling without support and

NHS will have to identify these incidental

training in management, which they need to

hybrids and find ways of either engaging

help them succeed.

them in genuine service improvement or

factors using postmortem computed tomography (PMCT) and whole body CT

The inclusion criteria were adult, nontraumatic, out-of-hospital cardiac arrest patients who were transported to our emergency room between April 1, 2008 and March 31, 2013. Following CPR, PMCT was performed in patients who died without return of spontaneous circulation (ROSC). Similarly, CT scans were performed in patients who were successfully resuscitated within 72hours after ROSC. The injuries associated with CPR were analysed retrospectively on CT images. Results During the study period, 309 patients who suffered out-of hospital cardiac arrest were transported to our emergency room and received CPR; 223 were enrolled in the study. The CT images showed that 156 patients (70.0%) had rib fractures, and 18 patients (8.1%) had sternal fractures. Rib fractures were associated with older age (78.0 years vs. 66.0 years, p<0.01), longer duration of CPR (41min vs. 33min, p<0.01), p<0.01). All sternal fractures occurred with

others who wish to achieve this – those we

by managers with no medical expertise is

have called ‘willing hybrids’.”

inaccurate,” said Louise Fitzgerald, Visiting Professor (Organisational Change). “Hybrid managers, who combine managerial responsibilities with clinical or medical duties, outnumber the full-time managers by four to one. But many find the role a tough challenge, partly because of a historic conflict between how medical professionals view themselves and their roles and their perception of management, and partly because they have not been taught how to manage.” “Although our research has suggested that it may be more important to learn how to be a hybrid than to do management, even the most proactive hybrid managers can be slowed down by a lack of knowledge of basic issues – which can be taught,” she said. “Better management training alongside professional training, as well as

Willing hybrids often have to endure accusations from their fellow professionals of “going over to the dark side”, of becoming “a poacher turned gamekeeper… fraternising with the enemy”. Nevertheless, they were proactive in seeking service improvements and used their roles to disrupt and challenge unrealistic and out-dated professionalism. “Our research showed that these hybrids were interested in inter-professional teamwork, focused on delivering ‘the best service’ for patients collectively, in contrast to the institutionalised lone professional who focuses on individual patients” says Fitzgerald. “They were willing to challenge professionals who ignored resource limitations and were willing to work with government targets as a means of providing good patient care.”

rib fractures and were associated with a

improved financial rewards for those taking

greater number of rib fractures, higher age,

on a hybrid management role, would have

and a lower rate of ROSC than rib fractures

the benefits both of encouraging more

only cases. Bilateral pneumothorax was

professionals to become hybrids, and

management side of their roles on the

observed in two patients with rib fractures.

making them more effective when they do.”

job. This has an advantage in that they

• Hybrid managers tend to learn the

are not seen to distance themselves too Conclusions

Fitzgerald has identified two key issues

much from clinical or medical practice.

PMCT is useful for evaluating complications

that have an impact on the effectiveness of

However, some do not feel supported in

related to chest compression. Further

hybrid managers in the NHS:

their roles. Others are hampered by a lack of knowledge about management,

investigations with PMCT are needed to reduce complications and improve the quality of CPR.

• Medical professionals in all fields identify themselves as medics first and foremost.

RESUSCITATION Today - SPRING 2015

and lower rate of ROSC (26.3% vs. 55.3%,

encouraging them to vacate the role for “The popular image that the NHS is overrun

particularly in specialised areas such as change management.

EVIDENCE NEWS Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Stub D1, Bernard S2, Pellegrino V3, Smith K4, Walker T5, Sheldrake J3, Hockings L3, Shaw J6, Duffy SJ6, Burrell A7, Cameron P7,Smit DV3, Kaye DM6. Author information Abstract Introduction: Many patients who suffer cardiac arrest do not respond to standard cardiopulmonary resuscitation. There is growing interest in utilizing veno-arterial extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation (E-CPR) in the management of refractory cardiac arrest. We describe our preliminary experiences in establishing an E-CPR program for refractory cardiac arrest in Melbourne, Australia.

RESUSCITATION Today - SPRING 2015

Methods: The CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion) is a single center, prospective, observational study conducted at The Alfred Hospital. The CHEER protocol was developed for selected patients with refractory in-hospital and out-of-hospital cardiac arrest and involves mechanical CPR, rapid intravenous administration of 30mL/kg of ice-cold saline to induce intra-arrest therapeutic hypothermia, percutaneous cannulation of the femoral artery and vein by two critical care physicians and commencement of veno-arterial ECMO. Subsequently, patients with suspected coronary artery occlusion are transferred to the cardiac catheterization laboratory for coronary angiography. Therapeutic hypothermia (33°C) is maintained for 24h in the intensive care unit. Results: There were 26 patients eligible for the CHEER protocol (11 with OHCA, 15 with IHCA). The median age was 52 (IQR 38-60) years. ECMO was established in 24 (92%), with a median time from collapse until

initiation of ECMO of 56 (IQR 40-85) min. Percutaneous coronary intervention was performed on 11 (42%) and pulmonary embolectomy on 1 patient. Return of spontaneous circulation was achieved in 25 (96%) patients. Median duration of ECMO support was 2 (IQR 1-5) days, with 13/24 (54%) of patients successfully weaned from ECMO support. Survival to hospital discharge with full neurological recovery (CPC score 1) occurred in 14/26 (54%) patients. Conclusions: A protocol including E-CPR instituted by critical care physicians for refractory cardiac arrest which includes mechanical CPR, peri-arrest therapeutic hypothermia and ECMO is feasible and associated with a relatively high survival rate. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved. Keywords: Cardiac arrest; Extracorporeal membrane oxygenation; Resuscitation

“The CHEER protocol was developed for selected patients with refractory in-hospital and out-of-hospital cardiac arrest and involves mechanical CPR, rapid intravenous administration of 30mL/ kg of ice-cold saline to induce intra-arrest therapeutic hypothermia, percutaneous cannulation of the femoral artery and vein by two critical care physicians and commencement of veno-arterial ECMO.”

Resuscitation Today Conference Programme

Thursday 22nd October 2015

Kettering Conference Centre, Kettering, Northants NN15 6PB Time

Presentation

08.30 – 09.30

Registration

09.30 – 09.45

Introduction

09.45 – 10.30

Trauma…… 30 per cent More Lives Saved

10.30 – 11.15

Tea/Coffee, Exhibition

11.15 – 11.45

Intubation without Traditional Laryngoscopy – is this the Future?

11.45 – 12.15

Emersive Simulation and Resuscitation Theories

12.15 –13.30

Lunch and Exhibition

13.30 – 14.00

Incorporating Non-Technical Skills in Life Support Teaching

14.00 – 14.30

TBC

14.30 –15.15

Tea/Coffee, Exhibition

15.15 – 16.00

Speaker

Position

Professor Sir Keith Porter

Professor in Clinical Traumatology, University Hospital, Birmingham

Jamie Todd BSc Hons MCPara

Principle Consultant

Rob Clark

TBC

Mike Davis Facd Med TBC

TBC

Designing Telemedicine Solutions for the Remote Assessment of the Peri Arrest Patient

TBC

16.00 – 16.30

New Resuscitation Guidelines

TBC

16.30 – 17.00

New Resuscitation Guidelines Q&A

TBC

Topics & Speakers correct at the time of press but may be subject to change

Delegate Rates: £48 inc VAT (Student rate: £36 inc VAT) Cost includes: delegate bag, refreshments and the opportunity to visit over 50 trade stands. Early Bird Offer – Book by 31st March to secure a reduced delegate rate of £36.00 or pay £60.00 to also attend the Paramedic Conference taking place the previous day (saving £36.00)

To register call 01322 660434 or visit

www.lifeconnections.uk.com

EQUIPMENT NEWS SP Services SP Services has been delivering quality products at affordable prices for over 25 years, supplying everything you need in an emergency, from a single pack of plasters to the latest state of the art defibrillators and ECG’s. Not only does SP Services stock market leading medical products such as o_two emergency respiratory devices, they also provide many sought after industry renowned brands such as Parabag and Donway. SP stock a range of the o_two devices, from the NEW eSeries Ventilators and o_two Single-Use Open Circuit CPAP to the innovative SMART BAG® Manual Resuscitators, CAREvent® range of Resuscitators and Automatic Transport Ventilators, CPR and Oxygen Therapy products. The o_two ranges of products are world renowned for their exceptional quality and performance. The SMART BAG has been designed to allow the provision of consistent ventilations while almost completely eliminating the risks associated with conventional BVM ventilation.

The unique actuating mechanism hidden inside the neck bushing of the SMART BAG© actually responds to the rescuer and the patient. The e500 transport ventilator provides trained individuals with a safe and effective means of providing controlled ventilation during patient transport, respiratory and/or cardiac arrest, specifically designed for the demands of emergency, rescue, resuscitation and critical patient transport. Parabag are one of the most popular specialist equipment bags produced by SP Services, covering key equipment requirements for first responders and paramedics. The NEW Parabag range, available from Spring 2015 has been completely redesigned around functionality

and modern materials to ensure these quality products continue to be a gold standard within the specialist equipment baggage market. Developed with the latest Blood Borne Pathogen (BBP) resistant fabric which is designed with you, the Parabag consumer and infection control in mind means the bags are robust and easy to maintain in a hardwearing environment. The new features include rapid fix handles, robust access zips and fluid resistant coating to ensure it is both functional and durable. Reinforced stitches, anti-slip under cushion pads mean that these bags are designed to stand the test of time. Available in a range of colours, models and sizes so that you can find the right bag to meet your professions needs. An innovation for 2015 from SP is the NEW Donway range of Vacuum Mattress and Traction Splints. Building on the signature quality and versatility of existing Donway products the new vacuum mattress has a V-shaped body design that optimises the vacuum mattress capabilities, whilst at the same time drawing on enhanced internal chamber technology for superior stability throughout ensuring that immobilisation is achieved for a rescue or evacuation scenario. The mattress and splint are easy to store and transport meaning they are a fantastic addition to any rescue and evacuation kit. Quick and easy to apply and secure, the color coded straps make for a rapid securing of the patient. The vacuum mattress and splint add to the range of quality Donway emergency rescue equipment on the market. The NEW SP Services catalogue is out now, request your FREE COPY now via:

RESUSCITATION Today - SPRING 2015

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RESUSCITATION Today - SPRING 2015

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