Legal Authority for Infectious Disease Reporting in the United States: Case Study of the 2009 H1N1 Influenza Pandemic.

Tracking of infectious diseases is a public health core function essential to disease prevention and control. Each state mandates reporting of certain infectious diseases to public health authorities. These laws vary by state, and the variation could affect the ability to collect critical information. The 2009 H1N1 influenza pandemic served as a case study to examine the legal authority in the 50 states; Washington, DC; and New York City for mandatory infectious disease reporting, particularly for influenza and new or emerging infectious diseases. Our study showed reporting laws to be generally present and functioning well; nevertheless, jurisdictions should be mindful of their mandated parameters and review the robustness of their laws before they face a new or emerging disease outbreak.

CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system.

BACKGROUND: Cardiopulmonary resuscitation (CPR) quality during actual cardiac arrest has been found to be deficient in several recent investigations. We hypothesized that real-time feedback during CPR would improve the performance of chest compressions and ventilations during in-hospital cardiac arrest. METHODS: An investigational monitor/defibrillator with CPR-sensing and feedback capabilities was used during in-hospital cardiac arrests from December 2004 to December 2005. Chest compression and ventilation characteristics were recorded and quantified for the first 5 min of resuscitation and compared to a baseline cohort of arrest episodes without feedback, from December 2002 to April 2004. RESULTS: Data from 55 resuscitation episodes in the baseline pre-intervention group were compared to 101 resuscitations in the feedback intervention group. There was a trend toward improvement in the mean values of CPR variables in the feedback group with a statistically significant narrowing of CPR variable distributions including chest compression rate (104+/-18 to 100+/-13 min(-1); test of means, p=0.16; test of variance, p=0.003) and ventilation rate (20+/-10 to 18+/-8 min(-1); test of means, p=0.12; test of variance, p=0.04). There were no statistically significant differences between the groups in either return of spontaneous circulation or survival to hospital discharge. CONCLUSIONS: Real-time CPR-sensing and feedback technology modestly improved the quality of CPR during in-hospital cardiac arrest, and may serve as a useful adjunct for rescuers during resuscitation efforts. However, feedback specifics should be optimized for maximal benefit and additional studies will be required to assess whether gains in CPR quality translate to improvements in survival.

Characteristics of volunteers responding to emergencies in the Public Access Defibrillation Trial.

OBJECTIVES: To evaluate the characteristics of volunteers responding to emergencies in the North American Public Access Defibrillation (PAD) Trial. METHODS: The PAD Trial was a prospective evaluation of cardiac arrest survival in community facilities randomized to cardiopulmonary resuscitation (CPR) or to CPR with automated external defibrillators (AEDs). The PAD volunteers' characteristics were analyzed using Poisson regression clustered on the facility and offset by the number of emergency episodes to which volunteers were exposed. RESULTS: A total of 19,320 volunteers in 1260 facilities were trained to provide emergency care. Of these, 8169 volunteers were participating actively at their facility during a time when one or more emergency episodes occurred. There were 1971 emergency episodes responded to by 1245 volunteers. The treatment arm (CPR-only versus CPR+AED) was not associated with the likelihood of volunteer participation in an episode. Likewise, the volunteers' age or sex did not affect response. Volunteers more likely to respond were supervisory/management or security personnel, non-minority participants, volunteers with previous CPR training, volunteers with previous experience in emergency care and those who passed the PAD CPR skills follow-up test. Volunteers who had a formal education beyond a high school level were less likely to respond. CONCLUSIONS: Volunteers with previous emergency training and positions of responsibility in their facility had a greater likelihood of participation in medical emergencies in the PAD Trial.

Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest.

BACKGROUND: Cardiopulmonary resuscitation (CPR) and electrical defibrillation are the primary treatment options for ventricular fibrillation (VF). While recent studies have shown that providing CPR prior to defibrillation may improve outcomes, the effects of CPR quality remain unclear. Specifically, the clinical effects of compression depth and pauses in chest compression prior to defibrillation (pre-shock pauses) are unknown. METHODS: A prospective, multi-center, observational study of adult in-hospital and out-of-hospital cardiac resuscitations was conducted between March 2002 and December 2005. An investigational monitor/defibrillator equipped to measure compression characteristics during CPR was used. RESULTS: Data were analyzed from 60 consecutive resuscitations in which a first shock was administered for VF. The primary outcome was first shock success defined as removal of VF for at least 5s following defibrillation. A logistic regression analysis demonstrated that successful defibrillation was associated with shorter pre-shock pauses (adjusted odds ratio 1.86 for every 5s decrease; 95% confidence interval 1.10-3.15) and higher mean compression depth during the 30s of CPR preceding the pre-shock pause (adjusted odds ratio 1.99 for every 5mm increase; 95% confidence interval 1.08-3.66). CONCLUSIONS: The quality of CPR prior to defibrillation directly affects clinical outcomes. Specifically, longer pre-shock pauses and shallow chest compressions are associated with defibrillation failure. Strategies to correct these deficiencies should be developed and consideration should be made to replacing current-generation automated external defibrillators that require long pre-shock pauses for rhythm analysis.

Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest.

CONTEXT: The survival benefit of well-performed cardiopulmonary resuscitation (CPR) is well-documented, but little objective data exist regarding actual CPR quality during cardiac arrest. Recent studies have challenged the notion that CPR is uniformly performed according to established international guidelines. OBJECTIVES: To measure multiple parameters of in-hospital CPR quality and to determine compliance with published American Heart Association and international guidelines. DESIGN AND SETTING: A prospective observational study of 67 patients who experienced in-hospital cardiac arrest at the University of Chicago Hospitals, Chicago, Ill, between December 11, 2002, and April 5, 2004. Using a monitor/defibrillator with novel additional sensing capabilities, the parameters of CPR quality including chest compression rate, compression depth, ventilation rate, and the fraction of arrest time without chest compressions (no-flow fraction) were recorded. MAIN OUTCOME MEASURE: Adherence to American Heart Association and international CPR guidelines. RESULTS: Analysis of the first 5 minutes of each resuscitation by 30-second segments revealed that chest compression rates were less than 90/min in 28.1% of segments. Compression depth was too shallow (defined as <38 mm) for 37.4% of compressions. Ventilation rates were high, with 60.9% of segments containing a rate of more than 20/min. Additionally, the mean (SD) no-flow fraction was 0.24 (0.18). A 10-second pause each minute of arrest would yield a no-flow fraction of 0.17. A total of 27 patients (40.3%) achieved return of spontaneous circulation and 7 (10.4%) were discharged from the hospital. CONCLUSIONS: In this study of in-hospital cardiac arrest, the quality of multiple parameters of CPR was inconsistent and often did not meet published guideline recommendations, even when performed by well-trained hospital staff. The importance of high-quality CPR suggests the need for rescuer feedback and monitoring of CPR quality during resuscitation efforts.

Human factors impact successful lay person automated external defibrillator use during simulated cardiac arrest.

OBJECTIVE: With the dissemination of automated external defibrillators in the community, there is increasing lay person use, along with less formal automated external defibrillator training and retraining. Therefore, the "ease of use" factors related to the human-device interface may be vital for successful use. We sought to determine whether human factor differences would result in differences in parameters of successful or safe use by lay persons in the setting of simulated cardiac arrest. METHODS: We measured parameters of successful and safe use with two automated external defibrillator devices among two groups of volunteers, those trained with a brief video tape and those without any training (completely naive). Both devices (the Philips FR2 or the HS1) are used in public access defibrillator settings. Volunteers entered a mock cardiac arrest scenario after randomization to either the naive (untrained) group or to a video-trained group. RESULTS: Both the FR2 and HS1 were found to be completely safe when used by video-trained and by naive groups of participants, with no adverse events observed (total, n = 256). For both devices, video-trained participants demonstrated high rates of successful defibrillation in the simulated testing (86% for FR2 and 89% for HS1). With the FR2, video-trained participants were significantly more successful compared with naive, untrained participants (86% vs. 48% successful use; p < .001). However, for the HS1, there was no significant difference in success rates for the video-trained vs. naive, untrained groups (89% vs. 87%; p = .79). CONCLUSIONS: Both devices are safe with either video-trained or naive users. The successful use of each device is high when participants view the training videotape designed for the device. An important difference in successful use was observed for naive users where the HS1 showed improved successful use compared with the FR2. Because defibrillation in the community may increasingly be attempted by lay persons whose training is remote or who have not been trained at all, the "naive" scenario may be increasingly relevant to automated external defibrillator use. Collectively, these data support the notion that human factors associated with ease of use may play a critical factor in survival rates achieved by specific devices.