Assessment of chest compression interruptions during advanced cardiac life support.

AIM: To identify potentially avoidable factors responsible for chest compression interruptions and to evaluate the influence of chest compression fraction on achieving return of spontaneous circulation and survival to hospital discharge. METHODS: In this prospective observational study, each resuscitation managed by mobile medical teams from August 1st, 2016, to August 1st, 2018 was video recorded using a body-mounted GoPro camera. The duration of all chest compression interruptions was recorded and chest compression fraction was calculated. All actions causing an interruption of at least 10 s were analyzed. RESULTS: Two hundred and six resuscitations of both in- and out-of-hospital cardiac arrest patients were analysed. In total 1867 chest compression interruptions were identified. Of these, 623 were longer than 10 s in which a total of 794 actions were performed. In 4.3% of the registered pauses, cardiopulmonary resuscitation was interrupted for more than 60 s. The most performed actions during prolonged interruptions were rhythm/pulse checks (51.6%), installation/use of mechanical chest compression devices (11.1%), cardiopulmonary resuscitation provider switches (6.7%) and ETT placements (6.2%). No statistically significant relationship was found between chest compression fraction and return of spontaneous circulation or survival. CONCLUSION: The majority of chest compression interruptions during resuscitation were caused by prolonged rhythm checks, cardiopulmonary resuscitation provider switches, incorrect use of mechanical chest compression devices and ETT placement. No association was found between chest compression fraction and return of spontaneous circulation, nor an influence on survival. This was presumably caused by the high baseline chest compression fraction of >86%.

Assessment of the knowledge level and experience of healthcare personnel concerning CPR and early defibrillation: an internal survey.

BACKGROUND: In-hospital cardiac arrest (IHCA) is a major public health problem with significant mortality. Rapid cardiopulmonary resuscitation and early defibrillation is extremely connected to patient outcome. In this study, we aimed to assess the effects of a basic life support and defibrillation course in improving knowledge in IHCA management. METHODS: We performed a prospective observational study recruiting healthcare personnel working at Azienda Ospedaliero Universitaria Pisana, Pisa, Italy. Study consisted in the administration of two questionnaires before and after BLS-D course. The course was structured as an informative meeting and it was held according to European Resuscitation Council guidelines. RESULTS: 78 participants completed pre- and post-course questionnaires. Only 31.9% of the participants had taken part in a BLS-D before our study. After the course, we found a significative increase in the percentage of participants that evaluated their skills adequate in IHCA management (17.9% vs 42.3%; p < 0.01) and in the correct use of defibrillator (38.8% vs 67.9% p < 0.001). However, 51.3% of respondents still consider their preparation not entirely appropriate after the course. Even more, we observed a significant increase in the number of corrected responses after the course, especially about sequence performed in case of absent vital sign, CPR maneuvers and use of defibrillator. CONCLUSIONS: The training course resulted in significant increase in the level of knowledge about the general management of IHCA in hospital staff. Therefore, a simple intervention such as an informative meetings improved significantly the knowledge about IHCA and, consequently, can lead to a reduction of morbidity and mortality.

Cost-effectiveness of advanced life support and prehospital critical care for out-of-hospital cardiac arrest in England: a decision analysis model.

OBJECTIVES: This research aimed to answer the following questions: What are the costs of prehospital advanced life support (ALS) and prehospital critical care for out-of-hospital cardiac arrest (OHCA)? What is the cost-effectiveness of prehospital ALS? What improvement in survival rates from OHCA would prehospital critical care need to achieve in order to be cost-effective? SETTING: A single National Health Service ambulance service and a charity-funded prehospital critical care service in England. PARTICIPANTS: The patient population is adult, non-traumatic OHCA. METHODS: We combined data from previously published research with data provided by a regional ambulance service and air ambulance charity to create a decision tree model, coupled with a Markov model, of costs and outcomes following OHCA. We compared no treatment for OHCA to the current standard of care of prehospital ALS, and prehospital ALS to prehospital critical care. To reflect the uncertainty in the underlying data, we used probabilistic and two-way sensitivity analyses. RESULTS: Costs of prehospital ALS and prehospital critical care were £347 and £1711 per patient, respectively. When costs and outcomes of prehospital, in-hospital and postdischarge phase of OHCA care were combined, prehospital ALS was estimated to be cost-effective at £11 407/quality-adjusted life year. In order to be cost-effective in addition to ALS, prehospital critical care for OHCA would need to achieve a minimally economically important difference (MEID) in survival to hospital discharge of 3%-5%. CONCLUSION: This is the first economic analysis to address the question of cost-effectiveness of prehospital critical care following OHCA. While costs of either prehospital ALS and/or critical care per patient with OHCA are relatively low, significant costs are incurred during hospital treatment and after discharge in patients who survive. Knowledge of the MEID for prehospital critical care can guide future research in this field. TRIAL REGISTRATION NUMBER: ISRCTN18375201.

Measuring situation awareness and team effectiveness in pediatric acute care by using the situation global assessment technique.

Situation awareness (SA) is an important human factor and necessary for effective teamwork and patient safety. Human patient simulation (HPS) with video feedback allows for a safe environment where health care professionals can develop both technical and teamwork skills. It is, however, very difficult to observe and measure SA directly. The Situation Global Assessment Technique (SAGAT) was developed by Endsley to measure SA during real-time simulation. Our objective was to measure SA among team members during simulation of acute pediatric care scenarios on the medical ward and its relationship with team effectiveness. Twenty-four pediatric teams, consisting of two nurses, one resident, and one consultant, participated in three acute care scenarios, using high-fidelity simulation. Individual SAGAT scores contained shared and complimentary knowledge questions on different levels of SA. Within each scenario, two "freezes" were incorporated to assess SA of each team members' clinical assessment and decision-making. SA overlap within the team (team SA) was computed and compared to indicators of team effectiveness (time to goal achievement, consensus on primary problem, diagnosis, task prioritization, leadership, and teamwork satisfaction). In 13 scenarios (18%), the team failed to reach the primary goals within the prescribed time of 1200 s. There was no significant difference in failure of goal completion between the scripted scenarios; however, there was a significant difference between scenario 3 and the other scenarios in time to goal completion. In all three scenarios, SA overlap level 2 (consensus on primary problem during the first freeze and consensus on diagnosis during the second freeze) leads to significantly faster achievement of the predefined goals. There was a strong relationship between team SA on the primary problem and diagnosis and team SA on task prioritization. Consensus on leadership within the team was low. Teamwork satisfaction was more influenced by knowledge about the importance of the assigned task than outcome of the scenario.Conclusion: The use of SAGAT enables us to measure SA of team members during real-time simulation of acute care scenarios. Although there is no direct connection between team SA and goal achievement, SAGAT provides insight in differences in SA among team members, and the process of shared mental model formation. By measuring SA, issues that may improve team effectiveness (prioritizing tasks, enhancing shared mental models, and providing leadership) can be trained and assessed during medical team simulation, enhancing teamwork in health care settings. What is known? • Teamwork skills such as communication, leadership, and situational awareness have become increasingly recognized as essential for good performance in pediatric resuscitation. However, the assessment of pediatric team performance in these clinical situations has been traditionally difficult. • The Situation Awareness Global Assessment Technique (SAGAT) is a method of objectively and directly measuring SA during a team simulation using "freezes" at predetermined points in time with participants reporting on "what is going on" from their perspective on the situation. What is new? • We assessed SA, and its relationship with team effectiveness, in multidisciplinary pediatric teams performing simulated critical events in critically ill children on the medical ward using the SAGAT model, outside the emergency room setting. • In all three scenarios, consensus on the primary problem (shared mental model) leads to faster achievement of predefined goals. Consensus on leadership was overall low, without a significant impact on goal achievement.

Ambulance Density and Outcomes After Out-of-Hospital Cardiac Arrest.

BACKGROUND: In out-of-hospital cardiac arrest (OHCA), geographic disparities in outcomes may reflect baseline variations in patients' characteristics but may also result from differences in the number of ambulances providing basic life support (BLS) and advanced life support (ALS). We aimed at assessing the association between allocated ambulance resources and outcomes in OHCA patients in a large urban community. METHODS: From May 2011 to January 2016, we analyzed a prospectively collected Utstein database for all OHCA adults. Cases were geocoded according to 19 neighborhoods and the number of BLS (firefighters performing cardiopulmonary resuscitation and applying automated external defibrillator) and ALS ambulances (medicalized team providing advanced care such as drugs and endotracheal intubation) was collected. We assessed the respective associations of Utstein parameters, socioeconomic characteristics, and ambulance resources of these neighborhoods using a mixed-effect model with successful return of spontaneous circulation as the primary end point and survival at hospital discharge as a secondary end point. RESULTS: During the study period, 8754 nontraumatic OHCA occurred in the Greater Paris area. Overall return of spontaneous circulation rate was 3675 of 8754 (41.9%) and survival rate at hospital discharge was 788 of 8754 (9%), ranging from 33% to 51.1% and from 4.4% to 14.5% respectively, according to neighborhoods ( P<0.001). Patient and socio-demographic characteristics significantly differed between neighborhoods ( P for trend <0.001). After adjustment, a higher density of ambulances was associated with successful return of spontaneous circulation (respectively adjusted odds-ratio [aOR], 1.31 [1.14-1.51]; P<0.001 for ALS ambulances >1.5 per neighborhood and aOR, 1.21 [1.04-1.41]; P=0.01 for BLS ambulances >4 per neighborhood). Regarding survival at discharge, only the number of ALS ambulances >1.5 per neighborhood was significant (aOR, 1.30 [1.06-1.59] P=0.01). CONCLUSIONS: In this large urban population-based study of out-of-hospital cardiac arrests patients, we observed that allocated resources of emergency medical service are associated with outcome, suggesting that improving healthcare organization may attenuate disparities in prognosis.

Assessment Tools for Use During Anesthesia-Centric Pediatric Advanced Life Support Training and Evaluation.

BACKGROUND: Pediatric perioperative cardiac arrests are rare events that require rapid, skilled and coordinated efforts to optimize outcomes. We developed an assessment tool for assessing clinician performance during perioperative critical events termed Anesthesia-centric Pediatric Advanced Life Support (A-PALS). Here, we describe the development and evaluation of the A-PALS scoring instrument. METHODS: A group of raters scored videos of a perioperative team managing simulated events representing a range of scenarios and competency. We assessed agreement with the reference standard grading, as well as interrater and intrarater reliability. RESULTS: Overall, raters agreed with the reference standard 86.2% of the time. Rater scores concerning scenarios that depicted highly competent performance correlated better with the reference standard than scores from scenarios that depicted low clinical competence (P < 0.0001). Agreement with the reference standard was significantly (P < 0.0001) associated with scenario type, item category, level of competency displayed in the scenario, correct versus incorrect actions and whether the action was performed versus not performed. Kappa values were significantly (P < 0.0001) higher for highly competent performances as compared to lesser competent performances (good: mean = 0.83 [standard deviation = 0.07] versus poor: mean = 0.61 [standard deviation = 0.14]). The intraclass correlation coefficient (interrater reliability) was 0.97 for the raters' composite scores on correct actions and 0.98 for their composite scores on incorrect actions. CONCLUSIONS: This study provides evidence for the validity of the A-PALS scoring instrument and demonstrates that the scoring instrument can provide reliable scores, although clinician performance affects reliability.

Systematic review of the effectiveness of prehospital critical care following out-of-hospital cardiac arrest.

BACKGROUND: Improving survival after out-of-hospital cardiac arrest (OHCA) is a priority for modern emergency medical services (EMS) and prehospital research. Advanced life support (ALS) is now the standard of care in most EMS. In some EMS, prehospital critical care providers are also dispatched to attend OHCA. This systematic review presents the evidence for prehospital critical care for OHCA, when compared to standard ALS care. METHODS: We searched the following electronic databases: PubMed, EmBASE, CINAHL Plus and AMED (via EBSCO), Cochrane Database of Systematic Reviews, DARE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, NIHR Health Technology Assessment Database, Google Scholar and ClinicalTrials.gov. Search terms related to cardiac arrest and prehospital critical care. All studies that compared patient-centred outcomes between prehospital critical care and ALS for OHCA were included. RESULTS: The review identified six full text publications that matched the inclusion criteria, all of which are observational studies. Three studies showed no benefit from prehospital critical care but were underpowered with sample sizes of 1028-1851. The other three publications showed benefit from prehospital critical care delivered by physicians. However, an imbalance of prognostic factors and hospital treatment in these studies systematically favoured the prehospital critical care group. CONCLUSION: Current evidence to support prehospital critical care for OHCA is limited by the logistic difficulties of undertaking high quality research in this area. Further research needs an appropriate sample size with adjustments for confounding factors in observational research design.

e-Learning in Advanced Life Support-What factors influence assessment outcome?

AIM: To establish variables which are associated with favourable Advanced Life Support (ALS) course assessment outcomes, maximising learning effect. METHOD: Between 1 January 2013 and 30 June 2014, 8218 individuals participated in a Resuscitation Council (UK) e-learning Advanced Life Support (e-ALS) course. Participants completed 5-8h of online e-learning prior to attending a one day face-to-face course. e-Learning access data were collected through the Learning Management System (LMS). All participants were assessed by a multiple choice questionnaire (MCQ) before and after the face-to-face aspect alongside a practical cardiac arrest simulation (CAS-Test). Participant demographics and assessment outcomes were analysed. RESULTS: The mean post e-learning MCQ score was 83.7 (SD 7.3) and the mean post-course MCQ score was 87.7 (SD 7.9). The first attempt CAS-Test pass rate was 84.6% and overall pass rate 96.6%. Participants with previous ALS experience, ILS experience, or who were a core member of the resuscitation team performed better in the post-course MCQ, CAS-Test and overall assessment. Median time spent on the e-learning was 5.2h (IQR 3.7-7.1). There was a large range in the degree of access to e-learning content. Increased time spent accessing e-learning had no effect on the overall result (OR 0.98, P=0.367) on simulated learning outcome. CONCLUSION: Clinical experience through membership of cardiac arrest teams and previous ILS or ALS training were independent predictors of performance on the ALS course whilst time spent accessing e-learning materials did not affect course outcomes. This supports the blended approach to e-ALS which allows participants to tailor their e-learning experience to their specific needs.

Evaluación de dispositivo de asistencia ventricular cardiológico (DAV) / Evaluation of cardiological ventricular assist device (VAD)

INTRODUCCIÓN: Antecedentes: La insuficiencia es una anomalia de la estrutura o la función cardiacas que hace que el corazón no pueda suministrar oxígenio a una frecuencia acorde con las necesidades de los tejidos normales de llenado. Se define clinciamente como un síndrome con síntomas (disnea, edema de miembros inferiores, fatiga...) y signos tipicos (presión venosa yugular elevada, crepitantes pulmonares, latido apical desplazado...) consecuencia de la alteración estructural o de la función cardiacas. Aspectos Generales: La insuficiencia cardiaca es una enfermedad progresiva y letal, aún con tratamiento adecuado. Así, una vez establecido el diagnp´óstico de insuficiência cardiaca, la tasa de mortalidad es del 50% a los 4 años y el 40% de los pacientes ingresados por insuficiencia cardiaca fallece o reingresa durante el primer año. En situación de insuficiencia cardiaca grave refractaria, el pronóstico, con tratamiento médico, es aún peor, con una supervivencia al año menor de 25%, comparable al de las neoplasias más agresivas. Tecnología Sanitaria de Interés: Los dispositivos de asistencia ventricular (DAV) son aquellos capaces de generar flujo circulatorio para sustituir parcial o totalmente la función del corazón en situaciones agudas o crónicas de fracaso cardiaco severo que no responde a otros tratamientos. Los DAV pueden proporcionar apoyo hemodinámico al ventrículo izquierdo, al derecho o a ambos, e incluso pueden sustituir completamente sus funciones. METODOLOGÍA: Estrategia de Búsqueda: Se realizó una búsqueda de la literatura con respecto a la eficacia y seguridad del uso de los Dispositivos de Asistencia Ventricular (DAV) en las bases de datos MEDLINE y TRIPDATABASE. Se hizo una búsqueda en www.clinicaltrials.gov, para poder identificar ensayos aún en elaboración o que no hayan sido publicados. Adicionalmente, se hizo una búsqueda dentro de la información generada por grupos que realizan revisiones sistemáticas, evaluación de tecnologías sanitarias y guías de práctica clínica, tales como The Cochrane Library y The National Institute for Health and Care Excellence (NICE). RESULTADOS: Se realizó la búsqueda bibliográfico y de evidencia científica para el sustento del uso de los DAV en pacientes candidato a trasplante. Se presenta la evidencia disponible en guías de práctica clínica, Evaluación de Tecnologías sanitarias, revisiones sistemáticas y ensayos clínicos. CONCLUSIONES: En la presente evaluación de tecnología sanitaria se evidencia la eficacia y seguridad del uso de los Dispositivos de Asistencia Ventricular (DAV) como puente al trasplante cardiaco. Se demuestra la alta tasa de supervivencia que tienen los pacientes con insuficiencia cardiaca terminal, a los cuales se le indicó el uso de un Dispositivio de Asistencia Ventricular como puente al tranplante cardiaco. Se evidencia la recuperación de la funcionalidad cardiaca y la calidad de vida de los pacientes con severidad progresiva a la insuficiencia cardiaca. Los estudios corroboran adicionalmente, que el uso del Dispositivo de Asistencia Ventricular están siendo utilizados para otras indicaciones, como los pacientes inotrópicos dependientes, los pacientes con riesgo de mortalidad al año y los que tienen falla de otros órganos.

Inequalities in the Access to Advanced Therapy in Heart Failure.

At present, heart failure (HF) is a worldwide problem, characterized by a high morbidity and mortality. In industrialized countries or regions, such as the United States, Canada, and western European countries, HF has a prevalence of 1.5% to 2.7%. Chile represents a growing economy in Latin America; however, the relatively high cost of more advanced therapies, in addition to other variables (ie, adequate and timely evaluation by HF specialists), makes access difficult for patients with HF. In this article, the authors review the principal difficulties in accessing advanced HF therapies in Chile, as a model of developing country.

An Equivalence Trial Comparing Instructor-Regulated With Directed Self-Regulated Mastery Learning of Advanced Cardiac Life Support Skills.

INTRODUCTION: Instructor-led simulation-based mastery learning of advanced cardiac life support (ACLS) skills is an effective and focused approach to competency-based education. Directed self-regulated learning (DSRL) may be an effective and less resource-intensive way to teach ACLS skills. METHODS: Forty first-year internal medicine residents were randomized to either simulation-based DSRL or simulation-based instructor-regulated learning (IRL) of ACLS skills using a mastery learning model. Residents in each intervention completed pretest, posttest, and retention test of their performance in leading an ACLS response to a simulated scenario. Performance tests were assessed using a standardized checklist. Residents in the DSRL intervention were provided assessment instruments, a debriefing guide, and scenario-specific teaching points, and they were permitted to access relevant online resources. Residents in the IRL intervention had access to the same materials; however, the teaching and debriefing were instructor led. RESULTS: Skills of both the IRL and DSRL interventions showed significant improvement after the intervention, with an average improvement on the posttest of 21.7%. After controlling for pretest score, there was no difference between intervention arms on the posttest [F(1,37) = 0.02, P = 0.94] and retention tests [F(1,17) = 1.43, P = 0.25]. Cost savings were realized in the DSRL intervention after the fourth group (16 residents) had completed each intervention, with an ongoing savings of $80 per resident. CONCLUSIONS: Using a simulation-based mastery learning model, we observed equivalence in learning of ACLS skills for the DSRL and IRL conditions, whereas DSRL was more cost effective.

Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support.

IMPORTANCE: Most out-of-hospital cardiac arrests receiving emergency medical services in the United States are treated by ambulance service providers trained in advanced life support (ALS), but supporting evidence for the use of ALS over basic life support (BLS) is limited. OBJECTIVE: To compare the effects of BLS and ALS on outcomes after out-of-hospital cardiac arrest. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of a nationally representative sample of traditional Medicare beneficiaries from nonrural counties who experienced out-of-hospital cardiac arrest between January 1, 2009, and October 2, 2011, and for whom ALS or BLS ambulance services were billed to Medicare (31,292 ALS cases and 1643 BLS cases). Propensity score methods were used to compare the effects of ALS and BLS on patient survival, neurological performance, and medical spending after cardiac arrest. MAIN OUTCOMES AND MEASURES: Survival to hospital discharge, to 30 days, and to 90 days; neurological performance; and incremental medical spending per additional survivor to 1 year. RESULTS: Survival to hospital discharge was greater among patients receiving BLS (13.1% vs 9.2% for ALS; 4.0 [95% CI, 2.3-5.7] percentage point difference), as was survival to 90 days (8.0% vs 5.4% for ALS; 2.6 [95% CI, 1.2-4.0] percentage point difference). Basic life support was associated with better neurological functioning among hospitalized patients (21.8% vs 44.8% with poor neurological functioning for ALS; 23.0 [95% CI, 18.6-27.4] percentage point difference). Incremental medical spending per additional survivor to 1 year for BLS relative to ALS was $154,333. CONCLUSIONS AND RELEVANCE: Patients with out-of-hospital cardiac arrest who received BLS had higher survival at hospital discharge and at 90 days compared with those who received ALS and were less likely to experience poor neurological functioning.

Trauma in pregnancy: assessment, management, and prevention.

Trauma complicates one in 12 pregnancies, and is the leading nonobstetric cause of death among pregnant women. The most common traumatic injuries are motor vehicle crashes, assaults, falls, and intimate partner violence. Nine out of 10 traumatic injuries during pregnancy are classified as minor, yet 60% to 70% of fetal losses after trauma are a result of minor injuries. In minor trauma, four to 24 hours of tocodynamometric monitoring is recommended. Ultrasonography has low sensitivity, but high specificity, for placental abruption. The Kleihauer-Betke test should be performed after major trauma to determine the degree of fetomaternal hemorrhage, regardless of Rh status. To improve the effectiveness of cardiopulmonary resuscitation, clinicians should perform left lateral uterine displacement by tilting the whole maternal body 25 to 30 degrees. Unique aspects of advanced cardiac life support include early intubation, removal of all uterine and fetal monitors, and performance of perimortem cesarean delivery. Proper seat belt use reduces the risk of maternal and fetal injuries in motor vehicle crashes. The lap belt should be placed as low as possible under the protuberant portion of the abdomen and the shoulder belt positioned off to the side of the uterus, between the breasts and over the midportion of the clavicle. All women of childbearing age should be routinely screened for intimate partner violence.

[Management of critically ill patients in the resuscitation room. Different than for trauma?]. / Schockraummanagement kritisch erkrankter Patienten. Anders als beim Trauma?

The general approach to the initial resuscitation of non-trauma patients does not differ from the ABCDE approach used to evaluate severely injured patients. After initial stabilization of vital functions patients are evaluated based on the symptoms and critical care interventions are initiated as and when necessary. Adequate structural logistics and personnel organization are crucial for the treatment of non-trauma critically ill patients although there is currently a lack of clearly defined requirements. For severely injured patients there are recommendations in the S3 guidelines on treatment of multiple trauma and severely injured patients and these can be modeled according to the white paper of the German Society of Trauma Surgery (DGU). However, structured training programs similar to the advanced trauma life support (ATLS®)/European resuscitation course (ETC®) that go beyond the current scope of advanced cardiac life support training are needed. The development of an advanced critically ill life support (ACILS®) concept for non-trauma critically ill patients in the resuscitation room should be supported.

Impact of High-Fidelity Simulation and Pharmacist-Specific Didactic Lectures in Addition to ACLS Provider Certification on Pharmacy Resident ACLS Performance.

PURPOSE: This pilot study explored the use of multidisciplinary high-fidelity simulation and additional pharmacist-focused training methods in training postgraduate year 1 (PGY1) pharmacy residents to provide Advanced Cardiovascular Life Support (ACLS) care. Pharmacy resident confidence and comfort level were assessed after completing these training requirements. METHODS: The ACLS training requirements for pharmacy residents were revised to include didactic instruction on ACLS pharmacology and rhythm recognition and participation in multidisciplinary high-fidelity simulation ACLS experiences in addition to ACLS provider certification. Surveys were administered to participating residents to assess the impact of this additional education on resident confidence and comfort level in cardiopulmonary arrest situations. RESULTS: The new ACLS didactic and simulation training requirements resulted in increased resident confidence and comfort level in all assessed functions. Residents felt more confident in all areas except providing recommendations for dosing and administration of medications and rhythm recognition after completing the simulation scenarios than with ACLS certification training and the didactic components alone. All residents felt the addition of lectures and simulation experiences better prepared them to function as a pharmacist in the ACLS team. CONCLUSION: Additional ACLS training requirements for pharmacy residents increased overall awareness of pharmacist roles and responsibilities and greatly improved resident confidence and comfort level in performing most essential pharmacist functions during ACLS situations.

Preoperative, intraoperative, and postoperative anesthesia assessment and monitoring in oral surgery.

This article discusses the general methods used to assess patients before, during, and after operative procedures, sedation, or general anesthesia by the oral and maxillofacial surgery team. The details about specific disease processes will be discussed in other articles. These methods and modalities are not standards, but are commonly used in offices and clinics in the United States where sedation and anesthesia are provided.

[Epidemiology and treatment analysis of children with out-of-hospital cardiac arrest].

OBJECTIVE: To study the weak loop in the treatment of children with out-of-hospital cardiac arrest (OHCA) and the treatment strategy for improvement. METHOD: Data of a total of 133 patients with OHCA who were rescued by Wuxi pre-hospital care center during the 2005 - 2011 were analyzed. RESULT: The main causes of pediatric OHCA were drowning (52/133) and accidental injury disease (30/133). The cases of OHCA were mainly located in public places (60/133) and the majority occurred in winter and summer. The emergency rescue response time was (13.21 ± 8.09) min, the rate of first witness treatment was 3.91%, intubations was performed in 11.11%, opening of vein access was 23.15% and one case got restoration of spontaneous circulation (ROSC). CONCLUSION: The rate of ROSC of pre-hospital cardiac arrest in children was significantly lower than that of hospital cardiac arrest. Preventive interventions on children's accidents and the skills of pre-hospital staff on pediatric advanced life support (PALS) need to be urgently improved.

EMS medical direction and prehospital practices for acute cardiovascular events.

OBJECTIVE: The purpose of this analysis was to determine whether there is an association between type of emergency medical services (EMS) medical direction and local EMS agency practices and characteristics specifically related to emergency response for acute cardiovascular events. METHODS: We surveyed 1,292 EMS agencies in nine states. For each cardiovascular prehospital procedure or practice, we compared the proportion of agencies that employed paid (full- or part-time) medical directors with the proportion of agencies that employed volunteer medical directors. We also compared the proportion of EMS agencies who reported direct interaction between emergency medical technicians (EMTs) and their medical director within the previous four weeks with the proportion of agencies who reported no direct interaction. Chi-square tests were used to assess statistical differences in proportion of agencies with a specific procedure by medical director employment status and medical director interaction. We repeated these comparisons using t-tests to evaluate mean differences in call volume. RESULTS: The EMS agencies with prehospital cardiovascular response policies were more likely to report employment of a paid medical director and less likely to report employment of a volunteer medical director. Similarly, agencies with prehospital cardiovascular response practices were more likely to report recent medical director interaction and less likely to report absence of recent medical director interaction. Mean call volumes for chest pain, cardiac arrest, and stroke were higher among agencies having paid medical directors (compared with agencies having volunteer medical directors) and agencies having recent medical director interaction (compared with agencies not having recent medical director interaction). CONCLUSIONS: Our study demonstrated that EMS agencies with a paid medical director and agencies with medical director interaction with EMTs in the previous four weeks were more likely to have prehospital cardiovascular procedures in place. Given the strong relationship that both employment status and direct interaction have with the presence of these practices, agencies with limited resources to provide a paid medical director or a medical director that can be actively involved with EMTs should be supported through partnerships and other interventions to ensure that they receive the necessary levels of medical director oversight.

Improving the efficiency of advanced life support training: a randomized, controlled trial.

BACKGROUND: Each year, more than 1.5 million health care professionals receive advanced life support (ALS) training. OBJECTIVE: To determine whether a blended approach to ALS training that includes electronic learning (e-learning) produces outcomes similar to those of conventional, instructor-led ALS training. DESIGN: Open-label, noninferiority, randomized trial. Randomization, stratified by site, was generated by Sealed Envelope (Sealed Envelope, London, United Kingdom). (International Standardized Randomized Controlled Trial Number Register: ISCRTN86380392) SETTING: 31 ALS centers in the United Kingdom and Australia. PARTICIPANTS: 3732 health care professionals recruited between December 2008 and October 2010. INTERVENTION: A 1-day course supplemented with e-learning versus a conventional 2-day course. MEASUREMENTS: The primary outcome was performance in a cardiac arrest simulation test at the end of the course. Secondary outcomes comprised knowledge- and skill-based assessments, repeated assessment after remediation training, and resource use. RESULTS: 440 of the 1843 participants randomly assigned to the blended course and 444 of the 1889 participants randomly assigned to conventional training did not attend the courses. Performance in the cardiac arrest simulation test after course attendance was lower in the electronic advanced life support (e-ALS) group compared with the conventional advanced life support (c-ALS) group; 1033 persons (74.5%) in the e-ALS group and 1146 persons (80.2%) in the c-ALS group passed (mean difference, -5.7% [95% CI, -8.8% to -2.7%]). Knowledge- and skill-based assessments were similar between groups, as was the final pass rate after remedial teaching, which was 94.2% in the e-ALS group and 96.7% in the c-ALS group (mean difference, -2.6% [CI, -4.1% to 1.2%]). Faculty, catering, and facility costs were $438 per participant for electronic ALS training and $935 for conventional ALS training. LIMITATIONS: Many professionals (24%) did not attend the courses. The effect on patient outcomes was not evaluated. CONCLUSION: Compared with conventional ALS training, an approach that included e-learning led to a slightly lower pass rate for cardiac arrest simulation tests, similar scores on a knowledge test, and reduced costs. PRIMARY FUNDING SOURCE: National Institute of Health Research and Resuscitation Council (UK).