Residual Psychomotor Skills of Orderlies After a Novel Chest Compression Training Intervention.

BACKGROUND: High-quality chest compressions are essential to favorable patient outcomes after in-hospital cardiac arrest. Without frequent training, however, skill in performing compressions declines considerably. The Timely Chest Compression Training (T-CCT) intervention was introduced in 2019 as a quality improvement initiative to address this problem. The long-term impact of the T-CCT is unknown. METHODS: A cohort study was conducted at a university-affiliated hospital in Quebec, Canada. Chest compression performance among orderlies was measured by using a subtractive scoring model and mannequins. The association of exposure to the T-CCT 10 months earlier with having an excellent chest compression performance (score ≥90 out of 100), after adjusting for potential confounders, was examined. RESULTS: A total of 412 orderlies participated in the study. More than half (n = 232, 56%) had been exposed to the T-CCT, and the rest (n = 180, 44%) had not. Nearly half (n = 106, 46%) of orderlies exposed to the T-CCT had an excellent performance, compared with less than one-third (n = 53, 30%) of nonexposed orderlies. In univariable analysis, previous exposure to the T-CCT was associated with 1.53 times greater risk of having an excellent performance (risk ratio, 1.53; 95% CI, 1.17-1.99). This effect remained after adjustment for potential confounders (risk ratio, 1.57; 95% CI, 1.19-2.07). CONCLUSION: The results of this study suggest that the T-CCT has a lasting effect on the psychomotor skills of orderlies 10 months after initial exposure. Further research should investigate the impact of the intervention on patient outcomes after in-hospital cardiac arrest.

Efficacy and cost-feasibility of the Timely Chest Compression Training (T-CCT): a contextualized cardiopulmonary resuscitation training for personal support workers participating during in-hospital cardiac arrests.

OBJECTIVES: The Timely Chest Compression Training (T-CCT) was created to promote more frequent training in chest compressions for personal support workers. This study aims to assess the efficacy of the T-CCT on the chest compression performance and to examine costs related to this intervention. METHODS: A prospective single group, before-after study was conducted at a university-affiliated hospital. The T-CCT is adapted for support workers and lasts 20 min during working hours. Guided by peer trainers, live feedback devices and mannikins, the T-CCT targets chest compression training. Using an algorithm, chest compression performance scores were gathered before and after the intervention. RESULTS: Of 875 employed support workers, 573 were trained in 5 days. Prior to the intervention, the median performance score was 72%. Participants significantly improved after the intervention (p < 0.001) and the median of the differences was 32% (95% CI 28.5-36.0). Support workers in critical care units and those with an active basic life support (BLS) certification performed better at baseline and were less inclined to have large changes in performance scores after the intervention. When compared to basic life support training, the T-CCT is over three times less expensive. CONCLUSIONS: The T-CCT was an effective and low-cost initiative that allowed to train a large group of support workers in a short amount of time. Since they are actively involved in resuscitation efforts in Quebec (Canada), it may promote the delivery of high-quality compressions during in-hospital cardiac arrests. Our inquiry can incite and guide other organizations in the implementation of similar interventions.

RéSUMé: OBJECTIFS: Le Timely Chest Compression Training (T-CCT) a été créé pour promouvoir une formation plus fréquente en compressions thoraciques pour les préposés aux bénéficiaires. Cette étude vise à évaluer l'efficacité du T-CCT sur la performance en compressions thoraciques et à examiner les coûts liés à cette intervention. MéTHODES: Une étude prospective avant-après avec un seul groupe a été menée dans un hôpital universitaire. Le T-CCT est adapté aux préposés aux bénéficiaires et dure 20 min pendant les heures de travail. Guidé par des pairs formateurs, des appareils de rétroaction en direct et des mannequins, le T-CCT cible l'entraînement des compression thoraciques. À l'aide d'un algorithme, les scores de performance en compression thoraciques ont été recueillis avant et après l'intervention. RéSULTATS: Sur les 875 préposés aux bénéficiaires employés, 573 ont été formés en cinq jours. Avant l'intervention, le score de performance médian était de 72 %. Les participants se sont nettement améliorés après l'intervention (p < 0.001) et la médiane des différences était de 32 % (IC à 95 %, 28.5−36.0). Les préposés aux bénéficiaires dans les unités de soins intensifs et ceux avec une formation de réanimation cardiorespiratoire de base (BLS) active ont obtenu de meilleurs résultats au départ et étaient moins enclins à avoir de grands changements dans leurs scores de performance après l'intervention. Comparé à la formation BLS, le T-CCT est trois fois moins cher. CONCLUSIONS: Le T-CCT était une initiative efficace et peu coûteuse qui a permis la formation d'un grand groupe de préposés aux bénéficiaires en peu de temps. Étant donné qu'ils sont activement impliqués dans les efforts de réanimation au Québec (Canada), cela pourrait favoriser la réalisation de compressions de grande qualité pendant les arrêts cardiorespiratoires en milieu hospitalier. Notre démarche pourra inciter et guider d'autres organisations dans la mise en œuvre d'interventions similaires.

Prognostic impact of the conversion to a shockable rhythm from a non-shockable rhythm for patients suffering from out-of-hospital cardiac arrest.

OBJECTIVE: For patients suffering from an out-of-hospital cardiac arrest (OHCA), having an initial shockable rhythm is a marker of good prognosis. It has been suggested as one of the main prognosticating factors for the selection of patients for extracorporeal resuscitation (E-CPR). However, the prognostic implication of converting from a non-shockable to a shockable rhythm, as compared to having an initial shockable rhythm, remains uncertain, especially among patients that can otherwise be considered eligible for E-CPR. The objective of this study was to evaluate the association between the initial rhythm and its subsequent conversion and survival following an OHCA, for the general population and for E-CPR candidates. METHODS: This study used a registry of OHCA in Montreal, Canada. Adult patients suffering from a non-traumatic OHCA for whom the initial rhythm was known were included. The association between the initial rhythm and its subsequent conversion or not and survival to discharge was assessed using a multivariable logistic regression. RESULTS: Of 6681 included patients, 1788 (27%) had an initial shockable rhythm, 1749 (26%) had pulseless electrical activity (PEA) and no subsequent shockable rhythm, 295 (4%) had PEA and a subsequent shockable rhythm, 2694 (40%) had asystole and no subsequent shockable rhythm, and 155 (2%) asystole and a subsequent shockable rhythm. As compared to patients having an initial shockable rhythm, patients in all other groups had significantly lower odds of survival to hospital discharge (p < 0.001 for all comparisons). Univariate analyses were performed for E-CPR candidates. Among these 556 (8%) patients, more patients with an initial shockable rhythm survived than patients in all other groups (p < 0.001 for all comparisons). CONCLUSIONS: The initial rhythm remains a much better prognostic marker than subsequent rhythms for all patients suffering from an OHCA, including in the subset of potential E-CPR candidates.

The prognostic significance of repeated prehospital shocks for out-of-hospital cardiac arrest survival.

OBJECTIVES: Patients suffering from an out-of-hospital cardiac arrest (OHCA) associated with an initial shockable rhythm have a better prognosis than their counterparts. The implications of recurrent or refractory malignant arrhythmia in such context remain unclear. The objective of this study is to evaluate the association between the number of prehospital shocks delivered and survival to hospital discharge among patients in OHCA. METHODS: This cohort study included adult patients with an initial shockable rhythm over a 5-year period from a registry of OHCA in Montreal, Canada. The relationship between the number of prehospital shocks delivered and survival to discharge was described using dynamic probabilities. The association between the number of prehospital shocks delivered and survival to discharge was assessed using multivariable logistic regression. RESULTS: A total of 1,788 patients (78% male with a mean age of 64 years) were included in this analysis, of whom 536 (30%) received treatments from an advanced care paramedic. A third of the cohort (583 patients, 33%) survived to hospital discharge. The probability of survival was highest with the first shock (33% [95% confidence interval 30%-35%]), but decreased to 8% (95% confidence interval 4%-13%) following nine shocks. A higher number of prehospital shocks was independently associated with lower odds of survival (adjusted odds ratio=0.88 [95% confidence interval 0.85-0.92], p < 0.001). CONCLUSION: Survival remains possible even after a high number of shocks for patients suffering from an OHCA with an initial shockable rhythm. However, requiring more shocks is independently associated with worse survival.

Impact of the direct transfer to percutaneous coronary intervention-capable hospitals on survival to hospital discharge for patients with out-of-hospital cardiac arrest.

AIMS: Patients suffering from out-of-hospital cardiac arrest (OHCA) are frequently transported to the closest hospital. Percutaneous coronary intervention (PCI) is often indicated following OHCA. This study's primary objective was to determine the association between being transported to a PCI-capable hospital and survival to discharge for patients with OHCA. The additional delay to hospital arrival which could offset a potential increase in survival associated with being transported to a PCI-capable center was also evaluated. METHODS: This study used a registry of OHCA in Montreal, Canada. Adult patients transported to a hospital following a non-traumatic OHCA were included. Hospitals were dichotomized based on whether PCI was available on-site or not. The effect of hospital type on survival to discharge was assessed using a multivariable logistic regression. The added prehospital delay which could offset the increase in survival associated with being transported to a PCI-capable center was calculated using that regression. RESULTS: A total of 4922 patients were included, of whom 2389 (48%) were transported to a PCI-capable hospital and 2533 (52%) to a non-PCI-capable hospital. There was an association between being transported to a PCI-capable center and survival to discharge (adjusted odds ratio = 1.60 [95% confidence interval 1.25-2.05], p < .001). Increasing the delay from call to hospital arrival by 14.0 min would offset the potential benefit of being transported to a PCI-capable center. CONCLUSIONS: It could be advantageous to redirect patients suffering from OHCA patients to PCI-capable centers if the resulting expected delay is of less than 14 min.

Potential impact of a prehospital redirection system for refractory cardiac arrest.

AIM: A change in prehospital redirection practice could potentially increase the proportion of E-CPR eligible patients with out-of-hospital cardiac arrest (OHCA) transported to extracorporeal cardiopulmonary resuscitation (E-CPR) capable centers. The objective of this study was to quantify this potential increase of E-CPR candidates transported to E-CPR capable centers. METHODS: Adults with non-traumatic OHCA refractory to 15min of resuscitation were selected from a registry of adult OHCA collected between 2010 and 2015 in Montreal, Canada. Using this cohort, three simulation scenarios allowing prehospital redirection to E-CPR centers were created. Stringent eligibility criteria for E-CPR and redirection for E-CPR (e.g. age <60years old, initial shockable rhythm) were used in the first scenario, intermediate eligibility criteria (e.g. age <65years old, at least one shock given) in the second scenario and inclusive eligibility criteria (e.g. age <70years old, initial rhythm ≠ asystole) in the third scenario. All three scenarios were contrasted with equivalent scenarios in which patients were transported to the closest hospital. Proportions were compared using McNemar's test. RESULTS: The proportion of E-CPR eligible patients transported to E-CPR capable centers increased in each scenario (stringent criteria: 48 [24.5%] vs 155 patients [79.1%], p<0.001; intermediate criteria: 81 [29.6%] vs 262 patients [95.6%], p<0.001; inclusive criteria: 238 [23.9%] vs 981 patients [98.5%], p<0.001). CONCLUSIONS: A prehospital redirection system could significantly increase the number of patients with refractory OHCA transported to E-CPR capable centers, thus increasing their access to this potentially life-saving procedure, provided allocated resources are planned accordingly.

Prehospital Advanced Cardiac Life Support for Out-of-hospital Cardiac Arrest: A Cohort Study.

OBJECTIVES: Out-of-hospital advanced cardiac life support (ACLS) has not consistently shown a positive impact on survival. Extracorporeal cardiopulmonary resuscitation (E-CPR) could render prolonged on-site resuscitation (ACLS or basic cardiac life support [BCLS]) undesirable in selected cases. The objectives of this study were to evaluate, in patients suffering from out-of-hospital cardiac arrest (OHCA) and in a subgroup of potential E-CPR candidates, the association between the addition of prehospital ACLS to BCLS and survival to hospital discharge, prehospital return of spontaneous circulation (ROSC), and delay from call to hospital arrival. METHODS: This cohort study targets adult patients treated for OHCA between April 2010 and December 2015 in the city of Montreal, Canada. We defined potential E-CPR candidates using clinical criteria previously described in the literature (65 years of age or younger, initial shockable rhythm, absence of ROSC after 15 minutes of prehospital resuscitation, and emergency medical services-witnessed collapse or witnessed collapse with bystander cardiopulmonary resuscitation). Associations were evaluated using multivariate regression models. RESULTS: A total of 7,134 patients with OHCA were included, 761 (10.7%) of whom survived to discharge. No independent association between survival to hospital discharge and the addition of prehospital ACLS to BCLS was found in either the entire cohort (adjusted odds ratio [AOR] = 1.05 [95% confidence interval {CI} = 0.84-1.32], p = 0.68) or among the 246 potential E-CPR candidates (AOR = 0.82 [95% CI = 0.36-1.84], p = 0.63). The addition of prehospital ACLS to BCLS was associated with a significant increase in the rate of prehospital ROSC in all patients experiencing OHCA (AOR = 3.92 [95% CI = 3.38-4.55], p < 0.001) and in potential E-CPR candidates (AOR = 3.48 [95% CI = 1. 76-6.88], p < 0.001) compared to isolated prehospital BCLS. Delay from call to hospital arrival was longer in the ACLS group than in the BCLS group (difference = 16 minutes [95% CI = 15-16 minutes], p < 0.001). CONCLUSIONS: In a tiered-response urban emergency medical service setting, prehospital ACLS is not associated with an improvement in survival to hospital discharge in patients suffering from OHCA and in potential E-CPR candidates, but with an improvement in prehospital ROSC and with longer delay to hospital arrival.

Is adequate pain relief and time to analgesia associated with emergency department length of stay? A retrospective study.

OBJECTIVES: Evaluate the association of adequate analgesia and time to analgesia with emergency department (ED) length of stay (LOS). SETTING AND DESIGN: Post hoc analysis of real-time archived data. PARTICIPANTS: We included all consecutive ED patients ≥18 years with pain intensity >6 (verbal numerical scale from 0 to 10), assigned to an ED bed, and whose pain was re-evaluated less than 1 h after receiving analgesic treatment. OUTCOME MEASURES: The main outcome was ED-LOS in patients who had adequate pain relief (AR=↓50% pain intensity) compared with those who did not have such relief (NR). RESULTS: A total of 2033 patients (mean age 49.5 years; 51% men) met our inclusion criteria; 58.3% were discharged, and 41.7% were admitted. Among patients discharged or admitted, there was no significant difference in ED-LOS between those with AR (median (25th-75th centile): 9.6 h (6.3-14.8) and 18.2 h (11.6-25.7), respectively) and NR (median (25th-75th centile): 9.6 h (6.6-16.0) and 17.4 h (11.3-26.5), respectively). After controlling for confounding factors, rapid time to analgesia (not AR) was associated with shorter ED-LOS of discharged and admitted patients (p<0.001 and <0.05, respectively). When adjusting for confounding variables, ED-LOS is shortened by 2 h (95% CI 1.1 to 2.8) when delay to receive analgesic is <90 min compared with >90 min for discharged and by 2.3 h (95% CI 0.17 to 4.4) for admitted patients. CONCLUSIONS: In our study, AR was not linked with short ED-LOS. However, rapid administration of analgesia was associated with short ED-LOS.