In-situ simulations to detect patient safety threats during in-hospital cardiac arrest.

Introduction: Errors during treatment may affect patient outcomes and can include errors in treatment algorithms, teamwork, and system errors. In-hospital cardiac arrests (IHCA) require immediate and effective treatment, and delays are known to reduce survival. In-situ simulation is a tool that can be used to study emergency responses, including IHCA. We investigated system errors discovered during unannounced in-situ simulated IHCA. Method: This multicenter cohort study included unannounced, full-scale IHCA in-situ simulations followed by a debriefing based on PEARLS with plus-delta used in the analysis phase. Simulations and debriefings were video-recorded for subsequent analysis. System errors observed were categorized by thematic analysis and analyzed for clinical implications. Errors related to treatment algorithm and clinical performance were excluded. Results: We conducted 36 in-situ simulations across 4 hospitals with a total discovery of 30 system errors. On average, we discovered 0.8 system errors per simulation within the categories: human, organizational, hardware, or software errors. Of these, 25 errors (83%) had direct treatment consequences. System errors caused treatment delays in 15 cases, a need for alternative actions in 6 cases, omission of actions in 4 cases, and other consequences in 5 cases. Conclusion: Using unannounced in-situ simulations, we identified almost one system error per simulation, and most of these errors were deemed to impact treatment negatively. The errors affected treatment by either causing delays, need for alternative treatment options, or omitting treatment actions. We suggest that hospitals focus on the need for regular testing of the emergency response by conducting full-scale unannounced in-situ simulations. This should be a priority to improve patient safety and care.

Thrombosis and pseudoaneurysm of the jugular vein.

Pseudoaneurysms and thrombosis in the jugular vein are very rare. This case report presents a case of a 57-year-old female with a thrombosis in the internal jugular vein and a pseudoaneurysm in the external jugular vein. The diagnosis is often delayed due to the less-frequent occurrence of either. Ultrasound and/or computer tomographic scan are useful in the diagnostic process. Pseudoaneurysms in the external jugular vein are often benign and treatment spans from none to surgical removal. The treatment of venous thrombosis is anticoagulant medication.

Inhospital cardiac arrest - the crucial first 5 min: a simulation study.

BACKGROUND: Early recognition and call for help, fast initiation of chest compressions, and early defibrillation are key elements to improve survival after cardiac arrest but are often not achieved. We aimed to investigate what occurs during the initial treatment of unannounced in situ simulated inhospital cardiac arrests and reasons for successful or inadequate initial resuscitation efforts. METHODS: We conducted unannounced full-scale in situ simulated inhospital cardiac arrest followed by a debriefing. Simulations and debriefings were video recorded for subsequent analysis. We analyzed quantitative data on actions performed and time measurements to key actions from simulations and qualitative data from transcribed debriefings. RESULTS: We conducted 36 simulations. Time to diagnosis of cardiac arrest was 37 (27; 55) s. Time to first chest compression from diagnosis of cardiac arrest was 37 (18; 74) s, time to calling the cardiac arrest team was 144 (71; 180) s, and time to first shock was 221 (181; 301) s. We observed participants perform several actions after diagnosing the cardiac arrest and before initiating chest compressions. Domains emerging from the debriefings were teaming and resources. Teaming included the themes communication, role allocation, leadership, and shared knowledge, which all included facilitators and barriers. Resources included the themes knowledge, technical issues, and organizational resources, of which all included barriers, and knowledge also included facilitators. CONCLUSION: Using unannounced in situ simulated cardiac arrests, we found that key elements such as chest compressions, calling the cardiac arrest team, and defibrillation were delayed. Perceived barriers to resuscitation performance were leadership and teaming, whereas experience, clear leadership, and recent training were perceived as important facilitators for treatment progress.

Barriers and facilitators for successful AED usage during in-situ simulated in-hospital cardiac arrest.

Introduction: Early defibrillation within minutes increases survival after in-hospital cardiac arrest (IHCA). However, early defibrillation is often not achieved even though automated external defibrillators (AEDs) are available. We aimed to investigate how AEDs were used and the barriers and facilitators for successful use. Methods: We conducted unannounced, full-scale in-situ simulations of IHCAs in hospital wards with an AED. A debriefing followed the simulations. The simulations and debriefings were video recorded, and the debriefings were transcribed for subsequent qualitative analysis about the AED use. Results: We conducted 36 unannounced in-situ simulations, and an AED was used in 98% of simulations. It was decided to collect an AED after a median of 62 (31; 123) seconds, the AED arrived after 99 (82; 146) seconds, were attached after 188 (150; 260) seconds, and the first shock were delivered after 221 (181; 301) seconds from time of cardiac arrest diagnosis. We identified three main domains related to barriers and facilitators of AED use: teamwork, knowledge, and transfer. Frequent reasons for successful use of an AED were recent resuscitation course, previous experience, and leadership. Reasons for unsuccessful use were doubt about responsibility, lack of knowledge, and lack of contextualized training. Conclusion: During unannounced simulated IHCAs, time to defibrillation was often > 3 minutes. Most of the delay occurred after the AED was collected. Non-technical skills and contextualized training were among the main perceived barriers to AED usage. Facilitators for successful use included recent training, previous experience, and successful leadership.

Distribution and use of automated external defibrillators and their effect on return of spontaneous circulation in Danish hospitals.

INTRODUCTION: Automated external defibrillators (AEDs) increase survival after out-of-hospital cardiac arrest. However, the effect of AEDs for in-hospital cardiac arrest (IHCA) remains uncertain. This study aims to describe the distribution and use of AEDs in Danish hospitals and investigate whether early rhythm analysis is associated with return of spontaneous circulation (ROSC). METHODS: All Danish public hospitals with a cardiac arrest team were included and sent a questionnaire on the in-hospital distribution of AEDs and manual defibrillators. Further, we collected data on IHCAs including rhythm analysis, device type, cardiac arrest team arrival, and ROSC from the national database on IHCA (DANARREST). RESULTS: Of 46 hospitals, 93% had AEDs and 93% had manual defibrillators. AEDs were often placed in wards or non-clinical areas, whereas manual defibrillators were often placed in areas with high-risk patients. We identified 3,204 IHCAs. AEDs were used in 13% of IHCAs. After adjustment for confounders, chance of ROSC was higher if the first rhythm analysis was performed before the arrival of the cardiac arrest team (RR: 1.28 (95% CI: 1.12-1.46)). The relative risk of ROSC was 1.09 (0.84-1.41) when analyzing with an AED before cardiac arrest team arrival and 1.19 (1.00-1.41) when using a manual defibrillator. However, there was no significant effect modification for AED vs manual defibrillator (p = 0.26). CONCLUSION: AEDs are widely distributed in Danish hospitals but less commonly used for IHCAs compared to manual defibrillators. Rhythm analysis before arrival of the cardiac arrest team was associated with ROSC without significant effect modification of device type.

Basic life support skills can be improved among certified basic life support instructors.

BACKGROUND: A correct visual skill demonstration is important when learning cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED). Basic life support (BLS) instructors are expected to master and demonstrate CPR/AED skills correctly. The aim of this study was to evaluate certified BLS instructors' competencies in demonstrating CPR and the use of an AED. METHODS: Certified BLS instructors demonstrated CPR and the use of an AED on a resuscitation manikin. Skills were evaluated using data collected from the manikin and video recordings and compared to resuscitation guidelines. Further, instructors completed questionnaires on resuscitation guidelines and rating of their own CPR/AED skills. RESULTS: Overall, we analyzed data from 125 instructors. Of all chest compressions, only 22% were within guideline recommendations regarding depth. Instructors performed chest compressions with excessive depth (mean depth 64 mm (7.3)) and a mean rate of 115 min-1 (10.8). Only 25% of instructors placed the left AED electrode correctly (median distance 7.6 cm (5.0;10.5)), while the right AED electrode usually was placed correctly (median distance 2.9 cm (1.5;4.0), 85% placed correctly). Nearly half of the instructors failed to state correct answers regarding how to diagnose a cardiac arrest and where to place the AED electrodes. Despite their performance, instructors rated their BLS skills as good. CONCLUSION: Certified BLS instructors' have poor CPR/AED skills and several important knowledge gaps on CPR/AED guidelines in contrast to instructors' self-reported skills. This highlights a need for improving BLS instructor education, including continuous faculty development to ensure optimal learning conditions for BLS course participants.

Comparing Surf Lifeguards and Nurse Anesthetists' Use of the i-gel Supraglottic Airway Device - An Observational Simulation Study.

PURPOSE: Using a supraglottic airway (SGA) may provide more effective ventilations compared with a mouth-to-pocket-mask for drowning victims. SGAs are widely used by nurse anesthetists but it is unknown whether surf lifeguards can use SGAs effectively. We aimed to compare the use of SGA by surf lifeguards and experienced nurse anesthetists. MATERIALS AND METHODS: Surf lifeguards inserted a SGA (i-gel O2, size 4) in a resuscitation manikin during cardiopulmonary resuscitation (CPR) and nurse anesthetists inserted a SGA in a resuscitation manikin placed on a bed, and performed ventilations. Outcome measures: time to first ventilation, tidal volume, proportion of ventilations with visible manikin chest rise, and ventilations within the recommended tidal volume (0.5-0.6 L). RESULTS: Overall, 30 surf lifeguards and 30 nurse anesthetists participated. Median (Q1-Q3) time to first ventilation was 20 s (15-22) for surf lifeguards and 17 s (15-21) for nurse anesthetists (p=0.31). Mean (SD) tidal volume was 0.55 L (0.21) for surf lifeguards and 0.31 L (0.10) for nurse anesthetists (p<0.0001). Surf lifeguards and nurse anesthetists delivered 100% and 95% ventilations with visible manikin chest rise (p=0.004) and 19% and 5% ventilations within the recommended tidal volume, respectively (p<0.0001). CONCLUSION: In a simulated setting, there was no significant difference between surf lifeguards and experienced nurse anesthetists in time to first ventilation when using a SGA. Surf lifeguards delivered a higher tidal volume, and a higher proportion of ventilations within guideline recommendations, but generally ventilations caused visible manikin chest rise for both groups.

Certified Basic Life Support Instructors Identify Improper Cardiopulmonary Resuscitation Skills Poorly: Instructor Assessments Versus Resuscitation Manikin Data.

INTRODUCTION: During basic life support (BLS) training, instructors assess learners' cardiopulmonary resuscitation (CPR) skills and correct errors to ensure high-quality performance. This study aimed to investigate certified BLS instructors' assessments of CPR skills. METHODS: Data were collected at BLS courses for medical students at Aarhus University, Aarhus, Denmark. Two certified BLS instructors evaluated each learner with a cardiac arrest test scenario, where learners demonstrated CPR on a resuscitation manikin for 3.5 minutes. Instructors' assessments were compared with manikin data as reference for correct performance. The first 3 CPR cycles were analyzed. Correct chest compressions were defined as 2 or more of 3 CPR cycles with 30 ± 2 chest compressions, 50 to 60 mm depth, and 100 to 120 min rate. Correct rescue breaths were defined as 50% or more efficient breaths with visible, but not excessive manikin chest inflation (for instructors) or 500 to 600mL air (manikin data). RESULTS: Overall, 90 CPR assessments were performed by 16 instructor pairs. Instructors passed 81 (90%) learners, whereas manikin pass rate was 2%. Instructors identified correct chest compressions with a sensitivity of 0.96 [95% confidence interval (CI) = 0.79-1) and a specificity of 0.05 (95% CI = 0.01-0.14), as well as correct rescue breaths with a sensitivity of 1 (95% CI = 0.40-1) and a specificity of 0.07 (95% CI = 0.03-0.15). Instructors mistakenly failed 1 learner with adequate chest compression depth, while passing 53 (59%) learners with improper depth. Moreover, 80 (89%) improper rescue breath performances were not identified. CONCLUSIONS: Certified BLS instructors assess CPR skills poorly. Particularly, improper chest compression depth and rescue breaths are not identified.

Differences in implementation strategies of the European Resuscitation Council Guidelines 2015 in Danish hospitals - a nationwide study.

INTRODUCTION: Guideline implementation is essential to improve survival following cardiac arrest. This study aimed to investigate awareness, expected time frame, and strategy for implementation of the European Resuscitation Council (ERC) Guidelines 2015 in Danish hospitals. METHODS: All public, somatic hospitals with a cardiac arrest team in Denmark were included. A questionnaire was sent to hospital resuscitation committees one week after guideline publication. The questionnaire included questions on awareness of ERC Guidelines 2015 and time frame and strategy for implementation. RESULTS: In total, 41 hospitals replied (response rate: 87%) between October 22 and December 22, 2015. Overall, 37% hospital resuscitation committees (n=15) were unaware of the guideline content. Most hospitals (80%, n=33) expected completion of guideline implementation within 6 months and 93% hospitals (n=38) expected the staff to act according to the ERC Guidelines 2015 within 6 months. In contrast, 78% hospitals (n=32) expected it would take between 6 months to 3 years for all staff to have completed a resuscitation course based on ERC Guidelines 2015. Overall, 29% hospitals (n=12) planned to have a strategy for implementation later than a month after guideline publication and 10% (n=4) hospitals did not plan to make a strategy. CONCLUSION: There are major differences in guideline implementation strategies among Danish hospitals. Many hospital resuscitation committees were unaware of guideline content. Most hospitals expected hospital staff to follow ERC Guidelines 2015 within six months after the publication even though they did not offer information or skill training to all staff members within that time frame.

Automated external defibrillation training on the left or the right side - a randomized simulation study.

BACKGROUND: Correct placement of the left automated external defibrillator (AED) electrode is rarely achieved. AED electrode placement is predominantly illustrated and trained with the rescuer sitting on the right side of the patient. Placement of the AED electrodes from the left side of the patient may result in a better overview of and access to the left lateral side of the thorax. This study aimed to investigate if training in automated external defibrillation on the left side compared to the right side of a manikin improves left AED electrode placement. METHODS: Laypeople attending basic life support training were randomized to learn automated external defibrillation from the left or right side of a manikin. After course completion, participants used an AED and placed AED electrodes in a simulated cardiac arrest scenario. RESULTS: In total, 40 laypersons were randomized to AED training on the left (n=19 [missing data =1], 63% female, mean age: 47.3 years) and right (n=20, 75% female, mean age: 48.7 years) sides of a manikin. There was no difference in left AED electrode placement when trained on the left or right side: the mean (SD) distances to the recommended left AED electrode position were 5.9 (2.1) cm vs 6.9 (2.2) cm (p=0.15) and to the recommended right AED electrode position were 2.6 (1.5) cm vs 1.8 (0.8) cm (p=0.06), respectively. CONCLUSION: Training in automated external defibrillation on the left side of a manikin does not improve left AED electrode placement compared to training on the right side.