Assessment of the speed and ease of insertion of three supraglottic airway devices by paramedics: a manikin study.

BACKGROUND: Control of the airway is a priority during cardiopulmonary resuscitation and/or following a failed intubation attempt. Supraglottic airway devices provide more effective airway management than bag-valve-mask-ventilation (BVMV) and can be effectively used by non-anaesthetists. METHODS: 36 paramedic students were timed to ascertain how long it took them to place an Igel, laryngeal mask airway (LMA) or laryngeal tube airway (LTA) into a manikin. Following insertion, students were interviewed to see which device they preferred and why. RESULTS: The Igel was consistently the fastest airway device, taking a mean of 12.3 s (95% CI 11.5 to 13.1) to insert, the LTA took a mean time of 22.4 s (95% CI 20.3 to 24.5) and the LMA 33.8 s (95% CI 30.9 to 36.7). 63% of students would choose the Igel as their preferred intermediate airway device, stating ease of use and speed of insertion as the primary reasons. CONCLUSION: The ease and speed at which a supraglottic airway can be inserted means that it is a viable alternative to the use of the BVMV.

Comparison of techniques for securing the endotracheal tube while wearing chemical, biological, radiological, or nuclear protection: a manikin study.

OBJECTIVE: The objective of this study was to assess the impact of chemical, biological, radiological, nuclear personal protective equipment (CBRN-PPE) on the ability to secure an endotracheal tube (ETT) with either the Thomas Tube Holder™ or cotton tape tied in a knot. METHODS: Seventy-five clinicians secured an ETT in a previously intubated manikin with the Thomas Tube Holder™ and cotton tape. A mixed quantitative and qualitative research design was used to gauge actual performance times and perceptions of difficulties. Following completion of the study, 25 clinicians were interviewed to gauge their experiences of securing the ETT with both devices while wearing CBRN-PPE. RESULTS: The mean time to apply the Thomas Tube Holder was 29.02 seconds, compared with tape which took a mean of 58 seconds (p=0.001). Clinicians rated the Thomas Tube Holder as easier to use than tape (Mann-Whitney z=9.934; p<0.001), which was confirmed during interviews. Of the clinicians interviewed, 92% perceived that the Thomas Tube Holder provided the better method for securing an ETT, none of the clinicians identified the tape as the best method for securing the endotracheal tube while wearing CBRN-PPE. Clinicians identified that the design of the Thomas Tube Holder facilitated the gross motor movement required for application. CONCLUSIONS: The Thomas Tube Holder is easier and faster to apply when wearing CBRN-PPE when compared with cotton, and the Thomas Tube Holder is perceived by the participants as being more effective at preventing accidential extubation.

Care after chemical, biological, radiation or nuclear events.

Prompt airway management after chemical, biological, radiation or nuclear (CBRN) incidents is crucial for patient survival. To date, however, the ideal airway device for use by healthcare professionals wearing CBRN-personal protective equipment has not been ascertained. This article discusses findings from a review of clinicians' experiences of using six intermediate airway devices for use while wearing personal protective equipment

Use of tourniquets in combat and civilian trauma situations.

The tourniquet as a method of catastrophic haemorrhage control on the battlefield has been in and out of favour over the centuries. However, the recent increase in incidence of blast injuries, in Afghanistan for example, has led to its recent reintroduction in the UK military as a potential treatment at the point of injury, and all UK soldiers are trained in its use. This article discusses the benefits and risks of using tourniquets, and considers whether they have a place in civilian practice in certain circumstances.

Acute myocardial infarction complicated by ventricular standstill terminated by thrombolysis and transcutaneous pacing.

Although the overall need for emergency pacing following AMI has reduced with the wide spread use of thrombolysis the availability of transcutaneous pacing offers an emergency non-invasive strategy to optimise circulation following CHB or ventricular standstill. Transcutaneous pacing also facilitates the safe instigation of thrombolytic therapy to achieve reperfusion of the conduction system following AMI.

Nebulised DNase in the treatment of life threatening asthma.

A 25-year-old pregnant patient developed life-threatening asthma refractory to all standard treatment including anaesthetic agents. Ventilatory pressures continued to rise with impending cardio-respiratory arrest. The introduction of nebulised endotracheal DNase however resulted in a rapid and dramatic improvement with good clinical outcome.

Perception gap in quality-of-life ratings: an empirical investigation of nursing home residents and caregivers.

PURPOSE: Several studies have previously documented the existence of a perception gap-the extent to which quality-of-life ratings provided by nursing home residents and caregivers diverge. In this study we use Helson's adaptation-level theory to investigate three types of antecedents: (a) focal factors, (b) background factors, and (c) residual factors. DESIGN AND METHODS: We calculated the perception gap for 11 quality-of-life domains. Caregivers rated both job satisfaction and their perception of quality of life of residents in the unit where they provided service. Concurrently, residents from these units completed quality-of-life interviews. We computed the perception gap by subtracting the residents' ratings from the caregivers' ratings for each quality-of-life domain. We conducted a hierarchical linear model using 3,850 observations to predict the perception gap. RESULTS: Caregivers perceive quality of life to be lower than residents do across all domains fairly consistently. Caregiver demographics do not directly predict the perception gap. However, satisfaction with work, pay, and promotion were significant predictors (p <.05), and satisfaction with supervisor was a marginally significant predictor (p <.10), of the perception gap. As satisfaction with these job dimensions increased, the perception gap decreased. Additional models show that several caregiver demographics directly influence job-satisfaction dimensions, though they did not influence the perception gap. IMPLICATIONS: Job-satisfaction dimensions, rather than caregiver characteristics, are the appropriate predictors of the perception gap. However, caregiver demographics exert their influence indirectly by means of job satisfaction. A key finding is that higher job satisfaction leads to a smaller perception gap. Helson's adaptation-level theory appears to be a useful approach for understanding the antecedents of the perception gap.

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.

Resuscitation of patients during pregnancy.

Although the risk of cardiac arrest during pregnancy is rare, the outcome for both mother and baby depends on effective resuscitation measures. Maternal resuscitations differ from other adult resuscitation attempts, and it is vital that emergency nurses can identify these variations in practice and apply them appropriately.

Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home.

OBJECTIVE: Quality improvement (QI) processes in nursing homes are highly variable and often ineffective. This study evaluated an innovative QI process to reduce pressure ulcers (PUs) in a nursing home with a high rate of PUs. DESIGN: This was a 48-week, longitudinal study comparing the incidence of PUs during 12-week baseline and intervention and post-intervention periods. SETTING: Not-for-profit, 136-bed nursing home in urban Western Pennsylvania. PATIENTS OR OTHER PARTICIPANTS: All residents and all staff at the nursing home participated in this study. INTERVENTIONS: The intervention consisted of 3 components: Ability enhancement, incentivization, and management feedback. To enhance ability, all staff members completed a computer-based interactive video education program on PU prevention and were mandated to use penlights to promote early detection. Incentivization included $75 for each staff member if the desired reduction in PU incidence was achieved. Management feedback provided real-time information of staff"s adherence to the mandated training. MAIN OUTCOME MEASURES: Outcome measures consisted of staff's adherence to mandated training and the incidence of new PUs during the baseline period compared to the intervention and post-intervention periods. RESULTS: Management responded to noncompliance with training with both rewards and stepped discipline. Adherence to protocol, as measured by training compliance, was 100%. There was a significant reduction (P < .05) in the incidence of stage 2 or worse PUs during the intervention period. During the post-intervention periods, the effect was lost. CONCLUSION: An innovative QI initiative resulted in a significant decrease in PUs in 1 facility. This intervention was not sustainable when the 3 components of the QI intervention were no longer actively maintained.

Reperfusion therapy.

In this article Nick Castle explains that, with significant improvements being made to the emergency management of cardiac patients, emergency nurses should challenge and develop their clinical practice to ensure patients receive prompt and evidence based treatment.

Bilateral tension pneumothorax.

The report discusses three patients who presented with pulseless electrical activity (PEA), caused by chronic respiratory disease, with bilateral tension pneumothorax. In each case needle decompression failed to relieve the tension and cardiac output was restored only after the insertion of a chest tube.

Pre-printed 'do not attempt resuscitation' forms improve documentation?

OBJECTIVE: Do not-attempt-resuscitate orders are fundamental for allowing patients to die peacefully without inappropriate resuscitation attempts. Once the decision has been made it is imperative to record this information accurately. However, during a related research projected we noted that documentation was poor and we thought that the introduction of a pre-printed Do Not Attempt Resuscitation (DNAR) form would improve the documentation process. DESIGN: Two sets of identical research questions were applied retrospectively, 12-months apart, to notes of adult patients (>18 years) who had died during a hospital admission without under-going a resuscitation attempt. Between the first and the second audit, a new resuscitation policy that incorporated a pre-printed DNAR form was introduced into our hospital. RESULTS: A pre-printed DNAR form improved documentation when measured against; clarity of DNAR order (P=0.05), date decision was made/implementation (P=0.014), presence of clinician's signature (P=0.001), identification of the senior clinician making the decision (P< or =0.001) and justification for the DNAR decision (P< or =0.001). However, the pre-printed form made little improvement in encouraging patient involvement in the DNAR decision-making process (P=0.348). CONCLUSION: A pre-printed DNAR form can improve documentation significantly but it has little effect in encouraging patient involvement in the decision-making process.

Health system costs of in-hospital cardiac arrest.

This paper reports on the health system resources used in the treatment of in-hospital cardiac arrests in a British district general hospital. The resources used in resuscitation attempts were recorded prospectively by observation of a convenience sample of 30 cardiac arrests. The post-resuscitation resource use by survivors was collected through a retrospective record review (n = 37) and by following survivor members in the prospective sample (n = 6). Financial data were used to translate resource use into costs (1999 prices). There was a non-significant trend for more resources to be used in daytime resuscitations than at night. Survivors had significantly fewer diagnostic tests during resuscitation than those who died (P = 0.004). Length of resuscitation attempt was positively and significantly related to resource use (P < 0.05). The average variable cost per resuscitation attempt (1999 prices) was 195.66 pounds sterling; 76.5% was for staff, and 13.1% for drugs and fluids. Emergency calls were attended by an average of 10.11 staff. The average fixed cost per resuscitation attempt was 928.81 pounds sterling; 12% for capital equipment and 73% for staff training. The average post-resuscitation costs attributable to the cardiac arrest of the 29 people surviving more than 24 h after cardio-pulmonary resuscitation (CPR) were estimated to be 1,589.72 pounds sterling. This is lower than other studies which estimated total costs of post-CPR lengths of stay. Reducing avoidable cardiac arrests would generate in-hospital savings in direct resuscitation care of survivors. Scope for reducing capital and training costs is discussed.

Avoidable cardiac arrest: lessons for an A&E department.

Deterioration to cardiac arrest is not always sudden and unexpected and on a significant number of occasions cardiac arrest could be prevented. This has important messages for the Accident and Emergency (A&E) department as the vast majority of emergency admissions originate via A&E.

Paediatric resuscitation: advanced life support.

The author describes the paediatric advanced life support algorithm and discusses specific aspects of paediatric resuscitation.