Skill decay following Basic Life Support training: a systematic review protocol.

INTRODUCTION: Survival from out of hospital cardiac arrest (OHCA) is lower in the UK than in several developed nations. Bystander cardiopulmonary resuscitation (CPR) is associated with increased rates of survival to hospital discharge following OHCA, prompting the introduction of several initiatives by the UK government to increase rates of bystander CPR, including the inclusion of Basic Life Support (BLS) teaching within the English national curriculum. While there is clear benefit in this, increasing evidence suggests poor retention of skills following BLS teaching. The aim of this systematic review is to summarise the literature regarding skill decay following BLS training, reporting particularly the time period over which this occurs, and which components of would-be rescuers' performance of the BLS algorithm are most affected. METHODS AND ANALYSIS: A search will be conducted to identify studies in which individuals have received BLS training and received subsequent assessment of their skills at a later date. A search strategy comprising relevant Medical Subject Headings (MeSH) terms and keywords has been devised with assistance from an experienced librarian. Relevant databases will be searched with titles, abstract and full-text review conducted independently by two reviewers. Data will be extracted from included studies by two reviewers, with meta-analysis conducted if the appropriate preconditions (such as limited heterogeneity) are met. ETHIC AND DISSEMINATION: No formal ethical approval is required for this systematic review. Results will be disseminated in the form of manuscript submission to a relevant journal and presentation at relevant meetings. To maximise the public's access to this review's findings, any scientific report will be accompanied by a lay summary posted via social media channels, and a press release disseminated to national and international news agencies. PROSPERO REGISTRATION NUMBER: CRD42021237233.

Spontaneous retropharyngeal haematoma with direct oral anticoagulant medication.

A 79-year-old man presented to the emergency department following a 1-week history of dyspnoea, dysphonia, dysphagia and a nonproductive cough. Previous medical history included atrial fibrillation, for which he was taking rivaroxaban, hypertension and obstructive sleep apnoea. On assessment, there was a mild stridor, swelling of the anterior aspect of the neck and submandibular bruising. CT of the neck demonstrated prevertebral soft tissue swelling extending from C1 to C6 levels, approximately 88 mm in length with a maximum depth of 25 mm. A diagnosis of spontaneous retropharyngeal haematoma was made: the airway was secured with fibreoptic nasal intubation and the patient admitted to the intensive care unit. Direct and fibreoptic assessment of the airway on day 3 confirmed that the haematoma had significantly reduced in size. The patient was extubated on day 4 and made a good recovery.

Biomarker-guided antibiotic stewardship in suspected ventilator-associated pneumonia (VAPrapid2): a randomised controlled trial and process evaluation.

BACKGROUND: Ventilator-associated pneumonia is the most common intensive care unit (ICU)-acquired infection, yet accurate diagnosis remains difficult, leading to overuse of antibiotics. Low concentrations of IL-1ß and IL-8 in bronchoalveolar lavage fluid have been validated as effective markers for exclusion of ventilator-associated pneumonia. The VAPrapid2 trial aimed to determine whether measurement of bronchoalveolar lavage fluid IL-1ß and IL-8 could effectively and safely improve antibiotic stewardship in patients with clinically suspected ventilator-associated pneumonia. METHODS: VAPrapid2 was a multicentre, randomised controlled trial in patients admitted to 24 ICUs from 17 National Health Service hospital trusts across England, Scotland, and Northern Ireland. Patients were screened for eligibility and included if they were 18 years or older, intubated and mechanically ventilated for at least 48 h, and had suspected ventilator-associated pneumonia. Patients were randomly assigned (1:1) to biomarker-guided recommendation on antibiotics (intervention group) or routine use of antibiotics (control group) using a web-based randomisation service hosted by Newcastle Clinical Trials Unit. Patients were randomised using randomly permuted blocks of size four and six and stratified by site, with allocation concealment. Clinicians were masked to patient assignment for an initial period until biomarker results were reported. Bronchoalveolar lavage was done in all patients, with concentrations of IL-1ß and IL-8 rapidly determined in bronchoalveolar lavage fluid from patients randomised to the biomarker-based antibiotic recommendation group. If concentrations were below a previously validated cutoff, clinicians were advised that ventilator-associated pneumonia was unlikely and to consider discontinuing antibiotics. Patients in the routine use of antibiotics group received antibiotics according to usual practice at sites. Microbiology was done on bronchoalveolar lavage fluid from all patients and ventilator-associated pneumonia was confirmed by at least 104 colony forming units per mL of bronchoalveolar lavage fluid. The primary outcome was the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage. Data were analysed on an intention-to-treat basis, with an additional per-protocol analysis that excluded patients randomly assigned to the intervention group who defaulted to routine use of antibiotics because of failure to return an adequate biomarker result. An embedded process evaluation assessed factors influencing trial adoption, recruitment, and decision making. This study is registered with ISRCTN, ISRCTN65937227, and ClinicalTrials.gov, NCT01972425. FINDINGS: Between Nov 6, 2013, and Sept 13, 2016, 360 patients were screened for inclusion in the study. 146 patients were ineligible, leaving 214 who were recruited to the study. Four patients were excluded before randomisation, meaning that 210 patients were randomly assigned to biomarker-guided recommendation on antibiotics (n=104) or routine use of antibiotics (n=106). One patient in the biomarker-guided recommendation group was withdrawn by the clinical team before bronchoscopy and so was excluded from the intention-to-treat analysis. We found no significant difference in the primary outcome of the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage in the intention-to-treat analysis (p=0·58). Bronchoalveolar lavage was associated with a small and transient increase in oxygen requirements. Established prescribing practices, reluctance for bronchoalveolar lavage, and dependence on a chain of trial-related procedures emerged as factors that impaired trial processes. INTERPRETATION: Antibiotic use remains high in patients with suspected ventilator-associated pneumonia. Antibiotic stewardship was not improved by a rapid, highly sensitive rule-out test. Prescribing culture, rather than poor test performance, might explain this absence of effect. FUNDING: UK Department of Health and the Wellcome Trust.

Use of the learning conversation improves instructor confidence in life support training: An open randomised controlled cross-over trial comparing teaching feedback mechanisms.

AIMS: Feedback is vital for the effective delivery of skills-based education. We sought to compare the sandwich technique and learning conversation structured methods of feedback delivery in competency-based basic life support (BLS) training. METHODS: Open randomised crossover study undertaken between October 2014 and March 2015 at the University of Birmingham, United Kingdom. Six-hundred and forty healthcare students undertaking a European Resuscitation Council (ERC) BLS course were enrolled, each of whom was randomised to receive teaching using either the sandwich technique or the learning conversation. Fifty-eight instructors were randomised to initially teach using either the learning conversation or sandwich technique, prior to crossing-over and teaching with the alternative technique after a pre-defined time period. Outcome measures included skill acquisition as measured by an end-of-course competency assessment, instructors' perception of teaching with each feedback technique and candidates' perception of the feedback they were provided with. RESULTS: Scores assigned to use of the learning conversation by instructors were significantly more favourable than for the sandwich technique across all but two assessed domains relating to instructor perception of the feedback technique, including all skills-based domains. No difference was seen in either assessment pass rates (80.9% sandwich technique vs. 77.2% learning conversation; OR 1.2, 95% CI 0.85-1.84; p=0.29) or any domain relating to candidates' perception of their teaching technique. CONCLUSIONS & RELEVANCE: This is the first direct comparison of two feedback techniques in clinical medical education using both quantitative and qualitative methodology. The learning conversation is preferred by instructors providing competency-based life support training and is perceived to favour skills acquisition.

Structured training in assessment increases confidence amongst basic life support instructors.

AIM: Assessment skills are often neglected in resuscitation training and it has been shown that the ERC BLS/AED instructor course may be insufficient to prepare candidates for an assessment role. We have introduced an Assessment Training Programme (ATP) to improve assessors' decision making. In this article we present our ATP and an observational study of candidates' confidence levels upon completing both an ERC BLS/AED instructor course and our ATP. METHODS: Forty-seven candidates undertook the ERC instructor course and 20 qualified ERC BLS/AED instructors undertook the ATP. Pre- and post-course questionnaires were completed. Confidence was assessed on ten-point Visual Analogue Scales (VAS). RESULTS: Overall confidence on the ERC BLS/AED instructor course rose from 5.9 (SD 1.8) to 8.7 (SD 1.4) (P < 0.001). A more modest improvement was witnessed on the ATP, rising from 8.2 (SD 1.4) to 9.6 (SD 0.5) (P < 0.001). Upon completion of their respective courses, assessors (mean 9.6, SD 0.5) were significantly more confident at assessing than instructors (mean 8.7, SD 0.5) (P<0.001). Confidence in assessing individual algorithm components was similar on both courses. On the post-course questionnaire those on the ATP remained significantly more confident at assessing borderline candidates compared to instructors (P < 0.001), with no difference for clear pass (P = 0.067) or clear fail (P = 0.060) candidates. CONCLUSION: The ATP raises the confidence of assessing BLS/AED candidates to a level above that of the ERC instructor course alone. We advocate that resuscitation organisations consider integrating an ATP into their existing training structure.

Prehospital anaesthesia performed by physician/critical care paramedic teams in a major trauma network in the UK: a 12†month review of practice.

INTRODUCTION: In the West Midlands region of the UK, delivery of pre-hospital care has been remodelled through introduction of a 24 h Medical Emergency Response Incident Team (MERIT). Teams including physicians and critical care paramedics (CCP) are deployed to incidents on land-based and helicopter-based platforms. Clinical practice, including delivery of rapid sequence induction of anaesthesia (RSI), is underpinned by standard operating procedures (SOP). This study describes the first 12 months experience of prehospital RSI in the MERIT scheme in the West Midlands. METHODS: Retrospective review of the MERIT clinical database for the 12 months following the launch of the scheme. Data was collected relating to the number of RSIs performed; indication for RSI; number of intubation attempts; grade of view on laryngoscopy and the base speciality/grade of the operator performing intubation. RESULTS: MERIT teams were activated 1619 times, attending scene in 1029 cases. RSI was performed 142 times (13.80% of scene attendances). There was one recorded case of failure to intubate requiring insertion of a supraglottic airway device (0.70%). In over a third of RSI cases, CCPs performed laryngoscopy and intubation (n=53, 37.32%). Proficiency of obtaining Grade I view at laryngoscopy was similar for physicians (74.70%) and CCPs (77.36%). Intubation was successful at the first attempt in over 90% of cases. CONCLUSIONS: This study demonstrates that operation within a system that provides high levels of exposure, underpinned by comprehensive and robust training and governance frameworks, promotes levels of performance in successful prehospital RSI regardless of base speciality or profession.

Rescuers may vary their side of approach to a casualty without impact on cardiopulmonary resuscitation performance.

AIM: To determine whether cardiopulmonary resuscitation (CPR) performance is influenced by a rescuer's preferred side of approach. METHODS: Eighty-three first-year healthcare students were enrolled in a prospective randomised crossover study comparing chest compression quality during uninterrupted chest compression CPR after approach from both their preferred and non-preferred sides. RESULTS: Chest compression quality was not dependent on rescuers' sidedness preference; neither mean compression rate and depth nor hand positioning differed between sides of approach. CONCLUSIONS: No link exists between the side from which a rescuer approaches, or prefers to approach, a casualty and chest compression quality.

An analysis of the introduction and efficacy of a novel training programme for ERC basic life support assessors.

AIM: Existing ERC BLS/AED accreditation procedures allow BLS instructors to assess the capability of BLS/AED providers, without undergoing additional training as an assessor. The reliability of instructor-based assessment has been questioned. This study sought to determine the efficacy of a simple training programme for BLS/AED instructors aimed at standardising assessment decisions. METHODS: An Assessment Training Programme (ATP) which provides additional, assessment-focused tuition for BLS instructors was introduced. Eighteen ERC accredited instructors participated in the study. Nine received standard ERC training (instructors); nine received additional training through the ATP (assessors). The assessment of 73 students' BLS/AED capabilities was carried out by an assessor, ERC instructor and ERC instructor trainer concurrently. Participants independently completed an ERC assessment form. Decisions for instructors and assessors were compared to the instructor trainers' decisions; those not agreeing were deemed to be incorrect. RESULTS: Instructors (49.3%) had lower raw pass rates than assessors (67.1%) and instructor trainers (64.4%). There was a significant difference in overall decisions between instructors and instructor trainers (p=0.035), and instructors and assessors (p=0.015). There was no difference between assessors and instructor trainers (p=0.824). Instructors were more prone to incorrectly failing candidates than assessors (sensitivities of 80.5% and 63.8% respectively, p=0.077). AED-capability decisions were significantly different from instructor trainers in both the instructor (p=0.007) and assessor groups (p=0.031). CONCLUSION: BLS instructors incorrectly fail candidates for reasons that should not normally constitute a true assessment failure. The ATP is an effective intervention to reduce false-failure rates and improve compliance with an experienced instructor trainer's decision. Consideration should be made to integrate such programmes into current BLS instructor accreditation procedures.

Rescuer fatigue under the 2010 ERC guidelines, and its effect on cardiopulmonary resuscitation (CPR) performance.

BACKGROUND: Updated life-support guidelines were published by the European Resuscitation Council (ERC) in 2010, increasing the required depth and rate of chest compression delivery. This study sought to determine the impact of these guidelines on rescuer fatigue and cardiopulmonary resuscitation (CPR) performance. METHODS: 62 Health science students performed 5 min of conventional CPR in accordance with the 2010 ERC guidelines. A SkillReporter manikin was used to objectively assess temporal change in determinants of CPR quality. Participants subjectively reported their end-fatigue levels, using a visual analogue scale, and the point at which they believed fatigue was affecting CPR delivery. RESULTS: 49 (79%) participants reported that fatigue affected their CPR performance, at an average of 167 s. End fatigue averaged 49.5/100 (range 0-95). The proportion of chest compressions delivered correctly decreased from 52% in min 1 to 39% in min 5, approaching significance (p=0.071). A significant decline in chest compressions reaching the recommended depth occurred between the first (53%) and fifth (38%) min (p=0.012). Almost half this decline (6%) was between the first and second minutes of CPR. Neither chest compression rate, nor rescue breath volume, were affected by rescuer fatigue. CONCLUSION: Fatigue affects chest compression delivery within the second minute of CPR under the 2010 ERC guidelines, and is poorly judged by rescuers. Rescuers should, therefore, be encouraged to interchange after 2 min of CPR delivery. Team leaders should be advised to not rely on rescuers to self-report fatigue, and should, instead, monitor for its effects.

Comparison of the quality of basic life support provided by rescuers trained using the 2005 or 2010 ERC guidelines.

INTRODUCTION: Effective delivery of cardiopulmonary resuscitation (CPR) and prompt defibrillation following sudden cardiac arrest (SCA) is vital. Updated guidelines for adult basic life support (BLS) were published in 2010 by the European Resuscitation Council (ERC) in an effort to improve survival following SCA. There has been little assessment of the ability of rescuers to meet the standards outlined within these new guidelines. METHODS: We conducted a retrospective analysis of the performance of first year healthcare students trained and assessed using either the new 2010 ERC guidelines or their 2005 predecessor, within the University of Birmingham, United Kingdom. All students were trained as lay rescuers during a standardised eight hour ERC-accredited adult BLS course. RESULTS: We analysed the examination records of 1091 students. Of these, 561 were trained and assessed using the old 2005 ERC guidelines and 530 using the new 2010 guidelines. A significantly greater proportion of candidates failed in the new guideline group (16.04% vs. 11.05%; p < 0.05), reflecting a significantly greater proportion of lay-rescuers performing chest compressions at too fast a rate when trained and assessed with the 2010 rather than 2005 guidelines (6.04% vs. 2.67%; p < 0.05). Error rates for other skills did not differ between guideline groups. CONCLUSIONS: The new ERC guidelines lead to a greater proportion of lay rescuers performing chest compressions at an erroneously fast rate and may therefore worsen BLS efficacy. Additional study is required in order to define the clinical impact of compressions performed to a greater depth and at too fast a rate.

A randomised control trial comparing two techniques for locating chest compression hand position in adult Basic Life Support.

INTRODUCTION: Chest compressions performed correctly have the potential to increase survival post cardiac arrest. The 2005 European Resuscitation Council (ERC) guidelines altered and simplified instructions for hand position placement to increase the number of chest compressions performed. This randomised controlled trial compares chest compression efficacy (hand position and number of effective chest compressions) after training using the 2005 guidelines or the 2005 guidelines with a hand position modification based on 2000 ERC guidelines. METHODS: First year healthcare students at the University of Birmingham, United Kingdom, were randomly allocated to either '2005' or 'intervention' group immediately after passing a Basic Life Support (BLS) assessment to ERC standards. The 2005 group performed 2 min of BLS on a SkillReporter™ manikin (Laerdal Medical, Stavanger, Norway). The intervention group received training on hand placement using landmark techniques from the 2000 ERC guidelines; emphasising rapid hand positioning. This group also performed 2 min of BLS on a SkillReporter™ manikin. RESULTS: 82 students were assessed; 41 in the 2005 group and 41 in the intervention group. Average compression rate was 102 in the 2005 group and 104 in the intervention group (p=0.29). Average number of incorrect hand placements was 24 in the 2005 group and 9 in the intervention group (p=0.03). CONCLUSIONS: The use of landmark measurement techniques in hand placement for external chest compressions does not have a detrimental effect on the number of chest compressions performed during BLS and increases correct hand positioning.

Comparison of the errors in basic life support performance after training using the 2000 and 2005 ERC guidelines.

The importance of immediate cardiopulmonary resuscitation (CPR) and defibrillation after cardiac arrest is established. The 2005 European Resuscitation Council (ERC) guidelines were altered to try to improve survival after cardiac arrest. This observational study compares the errors in basic life support (BLS) performance after training using the 2000 or 2005 guidelines. First-year healthcare students at the University of Birmingham, United Kingdom, were taught adult BLS in a standardised 8-h course: an historical group with previous ERC guidelines (Old), the other with 2005 ERC guidelines (New). 2537 (Old 1773; New 764) students were trained and assessed in BLS. There was no difference in overall error rate between Old and New (5.53% vs. 6.70% (p>0.05)) or adherence to the sequence of the respective BLS algorithm. The New group ("hands in centre of the chest") had significantly more erroneous hand positions compared to the Old group (5.23% vs. 1.64%, p<0.001). The 2005 ERC guidelines do not significantly improve correct BLS performance. Removal of hand placement measurement results in a significant increase in hand position errors. The clinical benefit of an increased number of compressions impaired by worsened hand positioning is unknown and requires further study.

Teaching recognition of agonal breathing improves accuracy of diagnosing cardiac arrest.

OBJECTIVE: Agonal breathing is present in up to 40% of pre-hospital cardiac arrests and is commonly mistaken as a sign of circulation leading to omission of bystander resuscitation. The aim of this study was to test the hypothesis that specific tuition on agonal breathing improves the accuracy of checking for signs of circulation as a diagnostic test for cardiac arrest. METHODS: First year medical students were randomised to control or intervention groups. The control group were taught standard CPR according to current guidelines. The intervention group received standard CPR training plus specific tuition on the characteristics of agonal breathing. Two weeks after initial training, the students' ability to recognise cardiac arrest was tested using a simulated cardiac arrest victim demonstrating normal, absent or agonal breathing. Diagnostic accuracy, sensitivity and specificity for the decision to start CPR was calculated. RESULTS: Sixty-four students were equally randomised to intervention and control groups. The intervention group had greater diagnostic accuracy for cardiac arrest compared to the control group (90% versus 78%, P=0.03). The intervention group were more likely to recognise cardiac arrest correctly and initiate CPR than the control group (sensitivity 90% versus 78%, P=0.02). The improved results were predominantly due to recognition that agonal breathing is a sign of cardiac arrest (75% intervention group versus 43% control group, P=0.01). CONCLUSION: This study demonstrates improved diagnostic accuracy and sensitivity of "checking for signs of circulation" by teaching CPR providers to recognise agonal breathing as a sign of cardiac arrest.

Birmingham assessment of breathing study (BABS).

BACKGROUND: Current international resuscitation guidelines for lay people rely on the assessment of "normal breathing" as a key sign of breathing and circulation. However, it is not known how accurately laypersons can discriminate between "normal" and "abnormal" breathing. The aim of this study was to test the ability of medical students to discriminate between simulated normal and abnormal breathing patterns and select the correct treatment. METHODS: Six video clips of simulated breathing were recorded showing: normal; abnormal -shallow, rapid, agonal (obstructed and unobstructed airways); or absent breathing. The clips were validated by three experienced emergency practitioners and then shown in a random order to 48 second-year medical students. For each clip observers were asked to indicate: "Is this patient breathing?" (yes-normal, yes-abnormal, no) and "What action would you take?" (rescue breathing or recovery position). RESULTS: All experts correctly identified the breathing type and agreed on an appropriate emergency action. Students identified normal breathing as: normal 61%, abnormal 33% and absent 6%; abnormal breathing as: normal 29%, abnormal 61%, absent 10%; and absent breathing as: normal 8%, abnormal 6%, absent 85%. Correct actions were selected in 86% during normal breathing, 51% during abnormal breathing and 86% during absent breathing. The sensitivity for observers correctly identifying normal from abnormal breathing was 60% and specificity 75% and for selecting the correct action was 42% and 80%, respectively. CONCLUSIONS: Medical students were unable to identify normal breathing from abnormal breathing reliably resulting in a high number of inappropriate, potentially harmful actions. Further evaluation of the optimal method for assessing for signs of breathing and circulation is required.

Use of advanced life support skills.

BACKGROUND: The Advanced Life Support (ALS) Provider Course trains healthcare professionals in a standardised approach to the management of a cardiac arrest. In the setting of limited resources for healthcare training, it is important that courses are fit for purpose in addressing the needs of both the individual and healthcare system. This study investigated the use of ALS skills in clinical practice after training on an ALS course amongst members of the cardiac arrest team compared to first responders. METHODS: Questionnaires measuring skill use after an ALS course were distributed to 130 doctors and nurses. RESULTS: 91 replies were returned. Basic life support, basic airway management, manual defibrillation, rhythm recognition, drug administration, team leadership, peri- and post-arrest management and resuscitation in special circumstances were used significantly more often by cardiac arrest team members than first responders. There was no difference in skill use between medically and nursing qualified first responders or arrest team members. CONCLUSION: We believe that the ALS course is more appropriately targeted to members of a cardiac arrest team. In our opinion the recently launched Immediate Life Support course, in parallel with training in the recognition and intervention in the early stages of critical illness, are more appropriate for the occasional or first responder to a cardiac arrest.