ABCDE cognitive aid tool in patient assessment - development and validation in a multicenter pilot simulation study.

BACKGROUND: The so called ABCDE approach (Airway-Breathing-Circulation-Disability-Exposure) is a golden standard of patient assessment. The efficacy of using cognitive aids (CA) in resuscitation and peri-arrest situations remains an important knowledge gap. This work aims to develop an ABCDE CA tool (CAT) and study its potential benefits in patient condition assessment. METHODS: The development of the ABCDE CAT was done by 3 rounds of modified Delphi method performed by the members of the Advanced Life Support Science and Education Committee of the European Resuscitation Council. A pilot multicentre study on 48 paramedic students performing patient assessment in pre-post cohorts (without and with the ABCDA CAT) was made in order to validate and evaluate the impact of the tool in simulated clinical scenarios. The cumulative number and proper order of steps in clinical assessment in simulated scenarios were recorded and the time of the assessment was measured. RESULTS: The Delphi method resulted in the ABCDE CAT. The use of ABCDE CAT was associated with more performed assessment steps (804: 868; OR = 1.17, 95% CI: 1.02 to 1.35, p = 0.023) which were significantly more frequently performed in proper order (220: 338; OR = 1.68, 95% CI: 1.40 to 2.02, p < 0.0001). The use of ABCDE CAT did not prolong the time of patient assessment. CONCLUSION: The cognitive aid for ABCDE assessment was developed. The use of this cognitive aid for ABCDE helps paramedics to perform more procedures, more frequently in the right order and did not prolong the patient assessment in advanced life support and peri-arrest care.

Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies.

BACKGROUND: Most Medicare patients seeking emergency medical transport are treated by ambulance providers trained in advanced life support (ALS). Evidence supporting the superiority of ALS over basic life support (BLS) is limited, but some studies suggest ALS may harm patients. OBJECTIVE: To compare outcomes after ALS and BLS in out-of-hospital medical emergencies. DESIGN: Observational study with adjustment for propensity score weights and instrumental variable analyses based on county-level variations in ALS use. SETTING: Traditional Medicare. PATIENTS: 20% random sample of Medicare beneficiaries from nonrural counties between 2006 and 2011 with major trauma, stroke, acute myocardial infarction (AMI), or respiratory failure. MEASUREMENTS: Neurologic functioning and survival to 30 days, 90 days, 1 year, and 2 years. RESULTS: Except in cases of AMI, patients showed superior unadjusted outcomes with BLS despite being older and having more comorbidities. In propensity score analyses, survival to 90 days among patients with trauma, stroke, and respiratory failure was higher with BLS than ALS (6.1 percentage points [95% CI, 5.4 to 6.8 percentage points] for trauma; 7.0 percentage points [CI, 6.2 to 7.7 percentage points] for stroke; and 3.7 percentage points [CI, 2.5 to 4.8 percentage points] for respiratory failure). Patients with AMI did not exhibit differences in survival at 30 days but had better survival at 90 days with ALS (1.0 percentage point [CI, 0.1 to 1.9 percentage points]). Neurologic functioning favored BLS for all diagnoses. Results from instrumental variable analyses were broadly consistent with propensity score analyses for trauma and stroke, showed no survival differences between BLS and ALS for respiratory failure, and showed better survival at all time points with BLS than ALS for patients with AMI. LIMITATION: Only Medicare beneficiaries from nonrural counties were studied. CONCLUSION: Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS. PRIMARY FUNDING SOURCE: National Science Foundation, Agency for Healthcare Research and Quality, and National Institutes of Health.

Hospice offers more palliative care but costs less than usual care for terminal geriatric hepatocellular carcinoma patients: a nationwide study.

BACKGROUND: Hospice care is important for patients with terminal hepatocellular carcinoma (HCC), especially in endemic areas of viral hepatitis. Differences between hospice care and usual care for geriatric HCC inpatients have not yet been explored in a nationwide survey. OBJECTIVE: The study's purpose was to analyze differences between hospice care and usual care for geriatric HCC inpatients in a nationwide survey. METHODS: This nationwide, population-based study used data obtained from the Taiwan National Health Insurance Database. Patients with terminal HCC who were ≥65 years old and received their end-of-life care in the hospital between January 2001 and December 2004 were recruited. The comparison group was selected by propensity score matching from patients receiving usual care in acute wards. RESULTS: We enrolled 729 terminal HCC patients receiving inpatient hospice care and 729 matched controls selected from 2482 HCC patients receiving usual care. Hospice care patients were treated mainly by family medicine doctors (36%) and oncologists (26%), while usual care patients were treated mainly by gastroenterologists (60.2%). The natural opium alkaloids were used more in the hospice care group than in the usual care group (72.7% versus 25.5%, P<0.001), whereas the length of stay (8±7.7 days versus 14.1±14.3 days, P<0.001), aggressive procedures (all P<0.005), and medical expenses (all P<0.001) were significantly less in the hospice care group. CONCLUSION: HCC patients in hospice wards received more narcotic palliative care, underwent fewer aggressive procedures, and incurred lower costs than those in acute wards. Hospice care should be promoted as a viable option for terminally ill, elderly HCC patients.

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

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

Concurrent care for the medically complex child: lessons of implementation.

After years of the palliative care community calling for more open access to hospice services, pediatric patients are now eligible to receive simultaneous hospice services and disease-directed therapy. We report on five types of challenges that our team has experienced when implementing concurrent care, illustrated through case studies of three medically complex pediatric patients.

The European Paediatric Life Support course improves assessment and care of dehydrated children in the emergency department.

We tested the hypothesis that application of the principles learned from the European Paediatric Life Support (EPLS) course improves child health assessment and care. In a retrospective study, residents from five paediatric emergency departments were included. For each of them, we analysed five medical records of infants and children suffering from diarrhoea; three were in ambulatory care and two were in-hospital care with IV hydration. Two independent observers analysed the records using a standardized checklist of 14 clinical points, as well as three items to evaluate the adequacy of treatment according to hydration status. Agreement between readers was evaluated the kappa coefficient of concordance. Statistical associations between each item and the EPLS course status was assessed by logistic regression taking into account the clustered data structure. Fifty residents and 240 medical records were included. Twenty-six residents were EPLS trained (intervention group) and 24 residents were not (control group). The results of the analyses of the medical records by the observers were concordant (kappa >0.91). Medical records in the intervention group contained more clinical information on circulatory status (P < 0.0001). Residents in the intervention group prescribed goal-directed therapy more often (P = 0.006). For children with shock, they administered volume resuscitation (P = 0.01) with goal-directed therapy more often (P = 0.003). This is the first evaluation of an educational program focusing on the actions of "learners" in the clinical environment. Our findings highlight that the EPLS course is associated with a better clinical analysis of hydration and circulation status as well as with goal-directed therapy.

End-of-life decisions in dutch neonatology.

This contribution describes the regulation of end-of-life decisions in neonatology in the Netherlands. An account is given of the process of formulating rules, which includes a report by the Dutch Association for Paediatrics, two Court rulings, a report by a Consultation Group appointed by the Ministry of Health and a professional Protocol regulating deliberate ending of life in neonatology that was subsequently adopted as the regulation of this type of decision-making at the national level. The paper presents Dutch and comparative data on the attitude of the medical profession towards end-of-life decisions in neonatology and the frequency of such decisions in medical practice.

Do all pediatric patients who have a febrile seizure require transport by advanced life support?

OBJECTIVE: In the state of New Jersey, all pediatric patients who are transported to the hospital by emergency medical services for seizures are evaluated by both advanced life support (ALS) and basic life support (BLS) units. The state triage protocol mandates that a paramedic unit be dispatched. The purpose of this study is establish that the subset of those patients who experience simple febrile seizures could be safely transported by BLS, subsequently freeing much needed ALS resources. METHODS: This study was performed using a retrospective chart review. Seventy-one consecutive patients who experienced febrile seizures and were transported to the Bristol-Meyers-Squib Children's Hospital/Robert Wood Johnson University Hospital via ALS were included. These patients were risk stratified into groups which were analyzed for interventions, including inpatient admission, medication delivery, intubation, or respiratory support. RESULTS: From this analysis, we are identified factors in the history and physical examination of patients in the field that would help to classify the patient as having a "simple febrile seizure" and thus significantly lowering the risk of any potential negative outcome. CONCLUSIONS: Simple febrile seizure patients are suitable for transport via BLS. Further studies should be done to confirm this conclusion.

Basic life support and children with profound and multiple learning disabilities.

Nurses and other carers of people with learning disabilities must be able to manage choking events and perform basic life support effectively. UK guidelines for assessment of airway obstruction and for resuscitation do not take account of the specific needs of people with profound multiple learning disability. For example, they fail to account for inhibited gag and coughing reflexes, limited body movements or chest deformity. There are no national guidelines to assist in clinical decisions and training for nurses and carers. Basic life support training for students of learning disability nursing at Birmingham City University is supplemented to address these issues. The authors ask whether such training should be provided for all nurses including those caring for children and young people. They also invite comment and discussion on questions related to chest compression and training in basic life support for a person in a seated position.

Confidence vs competence: basic life support skills of health professionals.

The provision of prompt effective resuscitation is fundamental in ensuring successful outcomes following cardiac arrest but historically nurses and doctors have lacked competence in performing basic life support (BLS), despite being confident in their abilities. The object of this study was to assess BLS confidence as assessed against competence of doctors' in-training, qualified nurses and healthcare assistants (HCAs) following the development of structured resuscitation training. This study has highlighted that the introduction of a structured resuscitation training programme has resulted in a noticeable improvement in BLS skills, particularly with regard to doctors. Registered nurses have improved with regular training compared with previously published data but HCAs tend to perform poorly and are under-confident. There remains a mismatch between confidence and competence, with only doctors demonstrating both confidence and competency and therefore changes to training programmes may be required to address this mismatch.

Non-voluntary passive euthanasia: the social consequences of euphemisms.

Non-voluntary passive euthanasia, the commonest form of euthanasia, is seldom mentioned in the UK. This article illustrates how the legal reasoning in Airedale NHS Trust v Bland contributed towards this conceptual deletion. By upholding the impermissibility of euthanasia, whilst at the same time permitting 'euthanasia' under the guise of 'withdrawing futile treatment', it is argued that the court (logically) allowed (withdrawing futile treatment and euthanasia). The Bland reasoning was incorporated into professional guidance, which extended the court's ruling to encompass patients who, unlike Anthony Bland, were sentient. But since the lawfulness of (withdrawing futile treatment and euthanasia) hinges on the futility of treatment, and since the guidance provides advice about withdrawing treatment from patients who differ from those considered in court, the lawfulness of such 'treatment decisions' is unclear. Legislation is proposed in order to redress the ambiguity that arose when moral decisions about 'euthanasia' were translated into medical decisions about 'treatment'.

Avaliação do conhecimento geral de médicos emergencistas de hospitais de Salvador - Bahia sobre o atendimento de vítimas com parada cardiorrespiratória / Assessment of the general knowledge of emergency physicians from the hospitals of the city of Salvador (Brazil) on the care of cardiac arrest patients

OBJETIVO: Identificar a proporção de médicos emergencistas com habilitação em cursos de imersão (SAVC - Suporte Avançado de Vida em Cardiologia e SAVT - Suporte Avançado de Vida no Trauma), relacionando variáveis: idade, sexo, especialidade médica, titulação e tipo de hospital com o grau de conhecimento teórico no atendimento de vítimas de parada cardiorrespiratória. MÉTODOS: Foram avaliados de forma consecutiva, de novembro/2003 a julho/2004, os emergencistas de hospitais públicos e privados da cidade de Salvador - Bahia, que voluntariamente aceitaram participar do estudo. Esses responderam a um questionário construído de informações das variáveis de interesse: perfil do profissional, realização ou não dos cursos de imersão SAVC e SAVT, avaliação cognitiva com 22 questões objetivas sobre ressuscitação cardiopulmonar. Calculou-se para cada participante um valor de acertos indicado como variável escore. Esse questionário foi validado a partir do resultado do escore dos instrutores do curso SAVC em Salvador - BA. RESULTADOS: Dos 305 médicos que responderam ao questionário, 83 (27,2 por cento) haviam realizado o curso SAVC, tendo como média da variável escore o valor de 14,9+3,0, comparada com os 215 médicos (70,5 por cento) que não o haviam feito e cuja média foi de 10,5+3,5 (p=0,0001). A média do escore dos 65 cardiologistas (21,5 por cento) foi de 14,1+3,3, comparada com os 238 médicos (78,5 por cento) que eram de outras especialidades, com média de 9,7+3,7(p=0,0001). Não foi identificada diferença da média do escore entre os médicos que haviam ou não realizado o curso SAVT (p=0,67). CONCLUSÃO: Na amostra avaliada, o conhecimento teórico sobre ressucitação cárdio-pulmonar (RCP) foi superior naqueles profissionais que realizaram o SAVC, diferente do que ocorreu naqueles que realizaram o SAVT. Os especialistas em Cardiologia que realizaram o SAVC demonstraram um conhecimento teórico superior, sobre o atendimento de vítimas de parada cárdio-respiratória (PCR), quando...

OBJECTIVE: To identify the proportion of emergency physicians certified in immersion courses (ACLS - Advanced Cardiac Life Support and ATLS - Advanced Trauma Life Support) correlating the variables of age, gender, medical specialty, academic title, and type of hospital with the level of theoretical knowledge on the care of Cardiac Arrest (CA) victims. METHODS: Emergency physicians from public and private hospitals of the city of Salvador, State of Bahia - Brazil, were consecutively evaluated from November, 2003 to July, 2004. They volunteered to participate in the study, and responded to a questionnaire consisting of information on the following variables of interest: professional profile, participation or not in ACLS and ATLS immersion courses, and cognitive assessment with 22 objective questions on Cardiopulmonary Resuscitation (CPR). A score of correct answers was calculated for each participant, and then designated as score variable. This questionnaire was validated based on the result of the score obtained by ACLS course instructors in Salvador, BA. RESULTS: Of the 305 physicians who responded to the questionnaire, 83 (27.2 percent) had attended the ACLS course and had a mean score variable of 14.9+3.0 compared with the 215 physicians (70.5 percent) who had not attended the course and whose mean was 10.5+ 3.5 (p=0.0001). The mean score of the 65 cardiologists (21.5 percent) was 14.1+3.3 compared with the mean of 9.7+3.7(p=0.0001) of the 238 physicians (78.5 percent) from other specialties. No difference was observed in the mean scores between physicians who had attended the ATLS course or not (p=0.67). CONCLUSION: In the sample studied, theoretical knowledge on CPR was higher among physicians who had attended the ACLS course, as opposed to those who had attended the ATLS course. Cardiologists who had attended the ACLS demonstrated a higher theoretical knowledge on the care of CA patients when compared to physicians from other specialties taken as whole - Internal...

[Assessment of physicians employed in emergency medical services about their level of knowledge on basic life support, advanced cardiac life support and medicolegal responsibilities]. / 112 Acil Saglik Hizmetleri'nde görevli doktorlarin temel yasam destegi, ileri kardiyak yasam destegi ve doktorun adli sorumluluklari konularindaki bilgi düzeylerinin degerlendirilmesi.

BACKGROUND: We aimed to determine the level of knowledge of Emergency Medical Services (EMS) physicians on Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS) and medicolegal responsibilities in conjunction with related factors. METHODS: Fifty-three physicians (43 male, 10 females; mean age 39 years; range 28 to 50 years) employed in EMS were required to respond a questionnaire consisting of demographic data and educational background. They also answered 25 multiple-choice questions about BLS, ACLS and medicolegal responsibilities of physicians in a face-to-face manner. The data were analyzed using Mann-Whitney U-test and Kruskal-Wallis Analysis of Variance test. RESULTS: Mean level of knowledge was 45.4 on a hundred-point scale. Attendance to courses covering emergency aid and working as an ambulance physician for more than one year were associated with higher levels of knowledge (p=0.012; p=0.015). CONCLUSION: In-service training should be undertaken to raise the level of knowledge of the physicians employed in rural EMS and to improve the quality of field care.