Clinical characteristics, causes and predictors of outcomes in patients with in-hospital cardiac arrest: results from the SURVIVE-ARREST study.

INTRODUCTION: In-hospital cardiac arrest (IHCA) is acutely life-threatening and remains associated with high mortality and morbidity. Identifying predictors of mortality after IHCA would help to guide acute therapy. METHODS: We determined patient characteristics and independent predictors of 30-day in-hospital mortality, neurological outcome, and discharge/referral pathways in patients experiencing IHCA in a large tertiary care hospital between January 2014 and April 2017. Multivariable Cox regression model was fitted to assess predictors of outcomes. RESULTS: A total of 368 patients with IHCA were analysed (median age 73 years (interquartile range 65-78), 123 (33.4%) women). Most patients (45.9%) had an initial non-shockable rhythm and shockable rhythms were found in 20.9%; 23.6% of patients suffered from a recurrent episode of cardiac arrest. 172/368 patients died within 30 days (46.7%). Of 196/368 patients discharged alive after IHCA, the majority (72.9%, n = 143) had a good functional neurological outcome (modified Rankin Scale ≤ 3 points). In the multivariable analysis, return of spontaneous circulation without mechanical circulatory support (hazard ratio (HR) 0.36, 95% confidence interval (CI) 0.21-0.64), invasive coronary angiography and/or percutaneous intervention (HR 0.56, 95% CI 0.34-0.92), and antibiotic therapy (HR 0.87, 95% CI 0.83-0.92) were associated with a lower risk of 30-day in hospital mortality. CONCLUSION: In the present study, IHCA was survived in ~ 50% in a tertiary care hospital, although only a minority of patients presented with shockable rhythms. The majority of IHCA survivors (~ 70%) had a good neurological outcome. Recovery of spontaneous circulation and presence of treatable acute causes of the arrest are associated with better survival. Clinical Characteristics, Causes and Predictors of Outcomes in Patients with In-Hospital Cardiac Arrest: Results from the SURVIVE-ARREST Study. ABBREVIATIONS: CPR, cardiopulmonary resuscitation; IHCA, In-hospital cardiac arrest; MCS, mechanical circulatory support; PCI, percutaneous coronary intervention; ROSC, return of spontaneous circulation; SBP, systolic blood pressure.

Virtual reality as a teaching method for resuscitation training in undergraduate first year medical students during COVID-19 pandemic: a randomised controlled trial.

BACKGROUND: Virtual reality (VR) is a computer-generated simulation technique which yields plenty of benefits and its application in medical education is growing. This study explored the effectiveness of a VR Basic Life Support (BLS) training compared to a web-based training during the COVID-19 pandemic, in which face-to-face trainings were disrupted or reduced. METHODS: This randomised, double-blinded, controlled study, enrolled 1st year medical students. The control group took part in web-based BLS training, the intervention group received an additional individual VR BLS training. The primary endpoint was the no-flow time-an indicator for the quality of BLS-, assessed during a structural clinical examination, in which also the overall quality of BLS (secondary outcome) was rated. The tertiary outcome was the learning gain of the undergraduates, assessed with a comparative self-assessment (CSA). RESULTS: Data from 88 undergraduates (n = 46 intervention- and n = 42 control group) were analysed. The intervention group had a significant lower no-flow time (p = .009) with a difference between the two groups of 28% (95%-CI [8%;43%]). The overall BLS performance of the intervention group was also significantly better than the control group with a mean difference of 15.44 points (95%-CI [21.049.83]), p < .001. In the CSA the undergraduates of the intervention group reported a significant higher learning gain. CONCLUSION: VR proved to be effective in enhancing process quality of BLS, therefore, the integration of VR into resuscitation trainings should be considered. Further research needs to explore which combination of instructional designs leads to deliberate practice and mastery learning of BLS.

Is Prehospital Assessment of qSOFA Parameters Associated with Earlier Targeted Sepsis Therapy? A Retrospective Cohort Study.

BACKGROUND: This study aimed to determine whether prehospital qSOFA (quick sequential organ failure assessment) assessment was associated with a shortened 'time to antibiotics' and 'time to intravenous fluid resuscitation' compared with standard assessment. METHODS: This retrospective study included patients who were referred to our Emergency Department between 2014 and 2018 by emergency medical services, in whom sepsis was diagnosed during hospitalization. Two multivariable regression models were fitted, with and without qSOFA parameters, for 'time to antibiotics' (primary endpoint) and 'time to intravenous fluid resuscitation'. RESULTS: In total, 702 patients were included. Multiple linear regression analysis showed that antibiotics and intravenous fluids were initiated earlier if infections were suspected and emergency medical services involved emergency physicians. A heart rate above 90/min was associated with a shortened time to antibiotics. If qSOFA parameters were added to the models, a respiratory rate ≥ 22/min and altered mentation were independent predictors for earlier antibiotics. A systolic blood pressure ≤ 100 mmHg and altered mentation were independent predictors for earlier fluids. When qSOFA parameters were added, the explained variability of the model increased by 24% and 38%, respectively (adjusted R² 0.106 versus 0.131 for antibiotics and 0.117 versus 0.162 for fluids). CONCLUSION: Prehospital assessment of qSOFA parameters was associated with a shortened time to a targeted sepsis therapy.

Effects of COVID-19 on in-hospital cardiac arrest: incidence, causes, and outcome - a retrospective cohort study.

BACKGROUND: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), an emerging virus, has caused a global pandemic. Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has led to high hospitalization rates worldwide. Little is known about the occurrence of in-hospital cardiac arrest (IHCA) and high mortality rates have been proposed. The aim of this study was to investigate the incidence, characteristics and outcome of IHCA during the pandemic in comparison to an earlier period. METHODS: This was a retrospective analysis of data prospectively recorded during 3-month-periods 2019 and 2020 at the University Medical Centre Hamburg-Eppendorf (Germany). All consecutive adult patients with IHCA were included. Clinical parameters, neurological outcomes and organ failure/support were assessed. RESULTS: During the study period hospital admissions declined from 18,262 (2019) to 13,994 (2020) (- 23%). The IHCA incidence increased from 4.6 (2019: 84 IHCA cases) to 6.6 (2020: 93 IHCA cases)/1000 hospital admissions. Median stay before IHCA was 4 (1-9) days. Demographic characteristics were comparable in both periods. IHCA location shifted towards the ICU (56% vs 37%, p < 0.01); shockable rhythm (VT/VF) (18% vs 29%, p = 0.05) and defibrillation were more frequent in the pandemic period (20% vs 35%, p < 0.05). Resuscitation times, rates of ROSC and post-CA characteristics were comparable in both periods. The severity of illness (SAPS II/SOFA), frequency of mechanical ventilation and frequency of vasopressor therapy after IHCA were higher during the 2020 period. Overall, 43 patients (12 with & 31 without COVID-19), presented with respiratory failure at the time of IHCA. The Horowitz index and resuscitation time were significantly lower in patients with COVID-19 (each p < 0.01). Favourable outcomes were observed in 42 and 10% of patients with and without COVID-19-related respiratory failure, respectively. CONCLUSION: Hospital admissions declined during the pandemic, but a higher incidence of IHCA was observed. IHCA in patients with COVID-19 was a common finding. Compared to patients with non-COVID-19-related respiratory failure, the outcome was improved.

Virtual reality as a teaching method for resuscitation training in undergraduate first year medical students: a randomized controlled trial.

BACKGROUND: Virtual reality is an innovative technology for medical education associated with high empirical realism. Therefore, this study compares a conventional cardiopulmonary resuscitation (CPR) training with a Virtual Reality (VR) training aiming to demonstrate: (a) non-inferiority of the VR intervention in respect of no flow time and (b) superiority in respect of subjective learning gain. METHODS: In this controlled randomized study first year, undergraduate students were allocated in the intervention group and the control group. Fifty-six participants were randomized to the intervention group and 104 participants to the control group. The intervention group received an individual 35-min VR Basic Life Support (BLS) course and a basic skill training. The control group took part in a "classic" BLS-course with a seminar and a basic skill training. The groups were compared in respect of no flow time in a final 3-min BLS examination (primary outcome) and their learning gain (secondary outcome) assessed with a comparative self-assessment (CSA) using a questionnaire at the beginning and the end of the course. Data analysis was performed with a general linear fixed effects model. RESULTS: The no flow time was significantly shorter in the control group (Mean values: control group 82 s vs. intervention group 93 s; p = 0.000). In the CSA participants of the intervention group had a higher learning gain in 6 out of 11 items of the questionnaire (p < 0.05). CONCLUSION: A "classic" BLS-course with a seminar and training seems superior to VR in teaching technical skills. However, overall learning gain was higher with VR. Future BLS course-formats should consider the integration of VR technique into the classic CPR training or vice versa, to use the advantage of both teaching techniques.

Challenges Faced by Prehospital Emergency Physicians Providing Emergency Care to Patients with Advanced Incurable Diseases.

INTRODUCTION: The aim of our study was to investigate challenges faced by emergency physicians (EPs) who provide prehospital emergency care to patients with advanced incurable diseases and family caregivers in their familiar home environment. METHODS: Qualitative study using semistructured interviews with open-ended questions to collect data from 24 EPs. Data were analyzed using qualitative content analysis. RESULTS: We identified nine categories of challenges: structural conditions of prehospital emergency care, medical documentation and orders, finding optimal patient-centered therapy, uncertainty about legal consequences, challenges at the individual (EP) level, challenges at the emergency team level, family caregiver's emotions, coping and understanding of patient's illness, patient's wishes, coping and understanding of patient's illness, and social, cultural, and religious background of patients and families. EPs strengthened that the integrations of specialized prehospital palliative care services improved emergency care by providing resources to patients and family caregivers, enhancing the quality and availability of medical documentation and accessibility of aftercare in emergencies. Areas of improvement that were identified were to promote emergency physicians' knowledge and skills in palliative care, communication, and family caregiver support by education and training. Furthermore, structures for better care on-site, thorough medical documentation, and specialized palliative care emergency facilities in hospital and prehospital care were requested. CONCLUSION: Prehospital emergency care in patients with advanced incurable diseases in their familiar home environment may be improved by training EPs in palliative care, communication, and caregiver support competences. Results underline the importance of collaborative specialized palliative care and prehospital emergency care.

Basic life support training using shared mental models improves team performance of first responders on normal wards: A randomised controlled simulation trial.

INTRODUCTION: Survival of in-hospital cardiac arrest (IHCA) depends on fast and effective action of the first responding team. Not only technical skills, but professional teamwork is required. Observational studies and theoretical models suggest that shared mental models of members improve teamwork. This study investigated if a training on shared mental models, improves team performance in simulated in-hospital cardiac arrest. METHODS: On the background of an introduction of mandatory Basic Life Support (BLS) training for clinical staff a randomized controlled trial was performed to compare two training methods. Staff from clinical departments was randomised to receive either a conventional instructor led training (control group) or an interventional training (intervention group). The interventional training was based on self-directed learning of the group in order to develop shared mental models. Primary outcome were mean scores of the team assessment scale (TAS) and the hands-off time. Secondary outcome were mean scores for quality of BLS. RESULTS: Performance of 75 teams of the interventional and 66 of the control group was analysed. The hands-off time was significantly lower in the interventional group (5.42% vs. 8.85%, p = 0.029). Scores of the TAS and the overall BLS score were high and not significantly different between the groups. Hands-off time correlated significantly negative with all TAS items. CONCLUSION: BLS training for clinical staff which creates shared mental models reduces hands-off time in a simulated cardiac arrest scenario. Training methods establishing shared mental models of team members can be considered for effective team trainings without adding additional training time.

Analyses of inter-rater reliability between professionals, medical students and trained school children as assessors of basic life support skills.

BACKGROUND: Training of lay-rescuers is essential to improve survival-rates after cardiac arrest. Multiple campaigns emphasise the importance of basic life support (BLS) training for school children. Trainings require a valid assessment to give feedback to school children and to compare the outcomes of different training formats. Considering these requirements, we developed an assessment of BLS skills using MiniAnne and tested the inter-rater reliability between professionals, medical students and trained school children as assessors. METHODS: Fifteen professional assessors, 10 medical students and 111-trained school children (peers) assessed 1087 school children at the end of a CPR-training event using the new assessment format. Analyses of inter-rater reliability (intraclass correlation coefficient; ICC) were performed. RESULTS: Overall inter-rater reliability of the summative assessment was high (ICC = 0.84, 95 %-CI: 0.84 to 0.86, n = 889). The number of comparisons between peer-peer assessors (n = 303), peer-professional assessors (n = 339), and peer-student assessors (n = 191) was adequate to demonstrate high inter-rater reliability between peer- and professional-assessors (ICC: 0.76), peer- and student-assessors (ICC: 0.88) and peer- and other peer-assessors (ICC: 0.91). Systematic variation in rating of specific items was observed for three items between professional- and peer-assessors. CONCLUSION: Using this assessment and integrating peers and medical students as assessors gives the opportunity to assess hands-on skills of school children with high reliability.

Peer education for BLS-training in schools? Results of a randomized-controlled, noninferiority trial.

BACKGROUND: The rate of bystanders who provide cardiopulmonary resuscitation (CPR) is low in Germany. To increase the bystander CPR rates of lay-rescuers in Germany, the national "einlebenretten" ("save one life") campaign was initiated, and the introduction of CPR-training for all seventh-grade students was recommended. To meet the requirement of offering effective and low-cost mass-training to lay-rescuers, we adopted peer education for the basic life support (BLS) training of the students. METHODS: We used an experimental, prospective, randomized, controlled, and open-label noninferiority trial to test whether the hands-on BLS training of the students that was provided by peers was inferior to the training by professional instructors using a predefined noninferiority margin of 5%. The students from eight different schools were trained in one 45 min practice session to perform BLS based on the educational framework provided by "einlebenretten". The students were randomly assigned to be trained either by peer-instructors (students in the same school who had been instructed in advance) or by professional instructors. In a structured practical assessment, the eight essential skills of BLS were tested and the examination was scored as either pass or fail. RESULTS: The study included 1087 students 14-18 years of age. The performance in the assessment was similar between the two groups: 40.3% (n=471) of the students in the peer-led group and 41.0% (n=466) in the professional-led group passed the examination. CONCLUSION: The students who were trained by peer-instructors showed comparable skills in BLS to the students who were trained by professional instructors. The sample size was too small to demonstrate the noninferiority of the peer-led training.

[Simulation-based training in anesthesia and emergency medicine: preparation for the unexpected: on the way to new standards of education in Germany]. / Simulationsbasiertes Training - Für den Notfall vorbereitet sein in Anästhesie und Notfallmedizin : Auf dem Weg zu neuen Standards der Ausbildung in Deutschland.

Medical expertise consists of knowledge, professional skills and individual attitudes. Training and education of this expertise starts in medical school and develops throughout the qualification process of anesthesists and emergency physicians. Medical decisions are not only rational but also intuitive. The combination of these characteristics cannot and should not be trained on patients. The implementation of modern simulation techniques offers the opportunity to train for emergency situations similar to training systems in the energy industry and aviation. Repetitive training of rare emergency situations brings routine to seldomly used procedures. In simulation training mistakes can be detected and systematically corrected. The team interactions and soft skills can also be focussed on. Video analysis gives the participant the opportunity for self-reflection and can lead to correction of individual behavior patterns. This dimension of education cannot be done in real patient care. This training goes far beyond the level of skills training. Through simulation training involves the whole team, the communication and the interaction between the team members in medically challenging situations. Crisis resource management leads to measurable improvements in patient safety and safety culture as well as personnel satisfaction.

A comparison between over-the-head and standard cardiopulmonary resuscitation performed by two rescuers: a simulation study.

BACKGROUND: In cardiopulmonary resuscitation (CPR) of a patient with an unsecured airway performed by two health care professionals, two methods are possible: 1) Standard CPR according to the guidelines, with one rescuer performing chest compressions from the side and the other rescuer performing ventilations from over the head of the patient. Additional tasks (like attaching the electrocardiogram and defibrillator) must be performed by the second rescuer during the time between ventilations. 2) Over-the-head CPR, with one rescuer performing chest compressions and ventilations from over the head and the other rescuer performing additional tasks. OBJECTIVES: The aim of this study was to compare the quality of CPR achieved by the two methods. METHODS: After a standardized theoretical introduction and practical training, 106 medical students with limited knowledge and training in CPR participated in this randomized crossover study. Students performed a 2-min CPR test of standard CPR in both positions and over-the-head CPR alone on a manikin. RESULTS: Standard CPR led to a significantly shorter hands-off-time over a 2-min interval than over-the-head CPR (median 25 s [interquartile range (IQR) 22-26 s] vs. 38 s [IQR 36-43 s], respectively, p < 0.001), and significantly more chest compressions (167 [IQR 158-176] vs. 142 [IQR 132-150], respectively, p < 0.001), more correct chest compressions (72 [IQR 11-136] vs. 45 [IQR 13-88], respectively, p = 0.004), inflations (10 [IQR 10-10] vs. 8 [IQR 8-8], respectively, p < 0.001), and correct inflations (5 [IQR 2-7] vs. 3 [IQR 1-4], respectively, p < 0.001). CONCLUSIONS: In the case of a two-professional-rescuer CPR scenario, standard CPR enables a quantitatively better resuscitation than over-the-head CPR.

ARX-derived auditory evoked potential index and bispectral index during the induction of anesthesia with propofol and remifentanil.

UNLABELLED: A new commercial auditory evoked potential (AEP) monitor (A-line AEP monitor) was developed to calculate an index (ARX AEP index; AAI) by automatically using the amplitudes and latencies of the AEP. We investigated 30 patients before spine surgery. AAI; bispectral index (BIS); relative (%) delta, theta, alpha, and beta; spectral edge frequency; median frequency; mean arterial blood pressure; heart rate; and oxygen saturation were obtained simultaneously during stepwise (1.0 micro g/mL) induction of target-controlled propofol concentration until 5.0 micro g/mL, followed by an infusion of 0.3 micro g. kg(-1). min(-1) of remifentanil. Every minute, the patients were asked to squeeze the observer's hand. Prediction probability (Pk), receiver operating characteristic, and logistic regression were used to calculate the probability to predict the conditions AWAKE, UNCONSCIOUSNESS (first loss of hand squeeze), and steady-state ANESTHESIA (5.0 micro g/mL of propofol and 0.3 micro g. kg(-1). min(-1) of remifentanil). Although a statistically significant difference among the conditions was observed for AAI, BIS, mean arterial blood pressure, median frequency, and %alpha, only AAI and BIS were able to distinguish UNCONSCIOUSNESS versus AWAKE and ANESTHESIA versus AWAKE with better than Pk = 0.90. The modern electroencephalographic variables AAI and BIS were superior to the classic electroencephalographic and hemodynamic variables to distinguish the observed anesthetic conditions. IMPLICATIONS: The modern electroencephalographic ARX-derived auditory evoked potential index and the bispectral index were superior to the classic electroencephalographic and hemodynamic variables for predicting anesthetic conditions. Variables derived from the auditory evoked potential did not provide an advantage over variables derived from spontaneous electroencephalogram.