Prehospital identification of acute ischaemic stroke with large vessel occlusion: a retrospective study from western Norway.

BACKGROUND: In 2019, the emergency medical services (EMS) covering the western Norway Regional Health Authority area implemented its version of the prehospital clinical criteria G-FAST (Gaze deviation, Facial palsy, Arm weakness, Visual loss, Speech disturbance) to detect acute ischaemic stroke (AIS) with large vessel occlusion (LVO). For patients with gaze deviation and at least one other G-FAST symptom, a primary stroke centre (PSC) may be bypassed and the patient taken directly to a comprehensive stroke centre (CSC) for rapid endovascular treatment (EVT) evaluation. The study aim was to investigate the efficacy of the G-FAST criteria for LVO patient selection and direct transfer to a CSC. METHODS: This retrospective study included patients with code-red emergency medical communication centre (EMCC) stroke suspicion ambulance dispatch between August to December 2020. Stroke suspicion was defined as having at least one G-FAST symptom at EMS arrival. We obtained patient data from dispatches from EMCCs, EMS records and local EVT registries. Clinical features, CT images, and reperfusion treatment were recorded. The test characteristics for gaze deviation plus one other G-FAST symptom in detecting LVO were determined. RESULTS: Among 643 patients, 59 were diagnosed with LVO at hospital arrival. In this group, seven fulfilled the G-FAST criteria for direct transport to a CSC at EMS arrival on scene, resulting in a sensitivity of 12% (95% CI 5% to 23%). The specificity was 99.66% (95% CI 98.77% to 99.96%), the positive predictive value 78%, and the negative predictive value 92%. EVT was performed in 64% (38/59) of LVO cases. Median time from PSC arrival to start of EVT at a CSC was 163 min. CONCLUSION: The use of local G-FAST prehospital criteria by EMS personnel to identify patients with AIS with LVO is not suitable for selection of patients with LVO for direct transfer to a CSC.

In situ simulation-based team training and its significance for transfer of learning to clinical practice-A qualitative focus group interview study of anaesthesia personnel.

BACKGROUND: Anaesthesia personnel are an integral part of an interprofessional operating room-team; hence, team-based training in non-technical skills (NTS) are important in preventing adverse events. Quite a few studies have been done on interprofessional in situ simulation-based team training (SBTT). However, research on anaesthesia personnel's experiences and the significance for transfer of learning to clinical practice is limited. The aim of this study is to explore anaesthesia personnel's experience from interprofessional in situ SBTT in NTS and its significance for transfer of learning to clinical practice. METHODS: Follow-up focus group interviews with anaesthesia personnel, who had taken part in interprofessional in situ SBTT were conducted. A qualitative inductive content analysis was performed. RESULTS: Anaesthesia personnel experienced that interprofessional in situ SBTT motivated transfer of learning and provided the opportunity to be aware of own practice regarding NTS and teamwork. One main category, 'interprofessional in situ SBTT as a contributor to enhance anaesthesia practice' and three generic categories, 'interprofessional in situ SBTT motivates learning and improves NTS', 'realism in SBTT is important for learning outcome', and 'SBTT increases the awareness of teamwork' illustrated their experiences. CONCLUSIONS: Participants in the interprofessional in situ SBTT gained experiences in coping with emotions and demanding situations, which could be significant for transfer of learning essential for clinical practice. Herein communication and decision-making were highlighted as important learning objectives. Furthermore, participants emphasized the importance of realism and fidelity and debriefing in the learning design.

Symptoms of post-traumatic stress disorder among first aid providers.

Background: Every year, large numbers of individuals are present or provide first aid in situations involving out-of-hospital cardiac arrest, injuries, or suicides. Little is known about the impact of providing first aid or witnessing a first aid situation, but research indicates that many first aid providers (FAP) experience persistent psychological difficulties. Here we aimed to assess the level of psychological impact of being a FAP. Methods: In this retrospective study, FAP attending follow-up were asked to complete the International Trauma Questionnaire (ITQ), which is a self-report diagnostic measure of post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD). We recorded endorsement of a symptom or functional impairment (score ≥ 2/4 on at least one of 18 items). Results: Of the 102 FAP in this study, 86 (84%) showed endorsement of a symptom or functional impairment. Common symptoms/functional impairments included being super-alert, watchful, or on guard; having powerful mental images; avoiding internal reminders or memories; and being affected in important parts of one's life. One-third had affected ability to work. Of the FAPs who attended follow-up more than one month after the incident (n = 32), 19% met the criteria for PTSD or CPTSD. Conclusions: The majority of FAPs have endorsement of a symptom or functional impairment. Some FAPs fulfil the criteria of PTSD. We suggest that follow-up should be offered by the EMS to all FAPs involved in incidents with an unconscious patient.

Is simulation-based team training performed by personnel in accordance with the INACSL Standards of Best Practice: SimulationSM?-a qualitative interview study.

BACKGROUND: Anesthesia personnel was among the first to implement simulation and team training including non-technical skills (NTS) in the field of healthcare. Within anesthesia practice, NTS are critically important in preventing harmful undesirable events. To our best knowledge, there has been little documentation of the extent to which anesthesia personnel uses recommended frameworks like the Standards of Best Practice: SimulationSM to guide simulation and thereby optimize learning. The aim of our study was to explore how anesthesia personnel in Norway conduct simulation-based team training (SBTT) with respect to outcomes and objectives, facilitation, debriefing, and participant evaluation. METHODS: Individual qualitative interviews with healthcare professionals, with experience and responsible for SBTT in anesthesia, from 51 Norwegian public hospitals were conducted from August 2016 to October 2017. A qualitative deductive content analysis was performed. RESULTS: The use of objectives and educated facilitators was common. All participants participated in debriefings, and almost all conducted evaluations, mainly formative. Preparedness, structure, and time available were pointed out as issues affecting SBTT. CONCLUSIONS: Anesthesia personnel's SBTT in this study met the International Nursing Association for Clinical Simulation and Learning (INACSL) Standard of Best Practice: SimulationSM framework to a certain extent with regard to objectives, facilitators' education and skills, debriefing, and participant evaluation.

Saving lives together. / Sammen redder vi liv.

Training in first aid has a long tradition in Norway. We believe that survival after time-critical events outside hospital can be further improved through systematic training.

Effects of modifiable prehospital factors on survival after out-of-hospital cardiac arrest in rural versus urban areas.

BACKGROUND: The modifiable prehospital system factors, bystander cardiopulmonary resuscitation (CPR), emergency medical services (EMS), response time, and EMS physician attendance, may affect short- and long-term survival for both rural and urban out-of-hospital cardiac arrest (OHCA) patients. We studied how such factors influenced OHCA survival in a mixed urban/rural region with a high survival rate after OHCA. METHODS: We analyzed the association between modifiable prehospital factors and survival to different stages of care in 1138 medical OHCA patients from an Utstein template-based cardiac arrest registry, using Kaplan-Meier type survival curves, univariable and multivariable logistic regression and mortality hazard plots. RESULTS: We found a significantly higher probability for survival to hospital admission (OR: 1.84, 95% CI 1.43-2.36, p < 0.001), to hospital discharge (OR: 1.51, 95% CI 1.08-2.11, p = 0.017), and at 1 year (OR: 1.58, 95% CI 1.11-2.26, p = 0.012) in the urban group versus the rural group. In patients receiving bystander CPR before EMS arrival, the odds of survival to hospital discharge increased more than threefold (OR: 3.05, 95% CI 2.00-4.65, p < 0.001). However, bystander CPR was associated with increased patient survival to discharge only in urban areas (survival probability 0.26 with CPR vs. 0.08 without CPR, p < 0.001). EMS response time ≥ 10 min was associated with decreased survival (OR: 0.61, 95% CI 0.45-0.83, p = 0.002), however, only in urban areas (survival probability 0.15 ≥ 10 min vs. 0.25 < 10 min, p < 0.001). In patients with prehospital EMS physician attendance, no significant differences were found in survival to hospital discharge (OR: 1.37, 95% CI 0.87-2.16, p = 0.17). In rural areas, patients with EMS physician attendance had an overall better survival to hospital discharge (survival probability 0.17 with EMS physician vs. 0.05 without EMS physician, p = 0.019). Adjusted for modifiable factors, the survival differences remained. CONCLUSIONS: Overall, OHCA survival was higher in urban compared to rural areas, and the effect of bystander CPR, EMS response time and EMS physician attendance on survival differ between urban and rural areas. The effect of modifiable factors on survival was highest in the prehospital stage of care. In patients surviving to hospital admission, there was no significant difference in in-hospital mortality or in 1 year mortality between OHCA in rural versus urban areas.

Semiprone position is superior to supine position for paediatric endotracheal intubation during massive regurgitation, a randomized crossover simulation trial.

BACKGROUND: Endotracheal intubation of patients with massive regurgitation represents a challenge in emergency airway management. Gastric contents tend to block suction catheters, and few treatment alternatives exist. Based on a technique that was successfully applied in our district, we wanted to examine if endotracheal intubation would be easier and quicker to perform when the patient is turned over to a semiprone position, as compared to the supine position. METHODS: In a randomized crossover simulation trial, a child manikin with on-going regurgitation was intubated both in the supine and semiprone positions. Endpoints were experienced difficulty with the procedure and time to intubation, as well as visually confirmed intubation and first-pass success rate. RESULTS: Intubation in the semiprone position was significantly easier and faster compared to the supine position; the median experienced difficulty on a visual analogue scale was 27 and 65, respectively (p = 0.004), and the median time to intubation was 26 and 45 s, respectively (p = 0.001). There were no significant differences in frequency of visually confirmed intubation (16 and 18, p = 0.490) of first-pass success rate (17 and 18, p = 1.000). CONCLUSION: In this experiment, endotracheal intubation during massive regurgitation with the patient in the semiprone position was significantly easier and quicker to perform than in the supine position. Endotracheal intubation in the semiprone position can provide a quick rescue method in situations where airway management is hindered by massive regurgitation, and it represents a possible supplement to current airway management training.

Improving Survival after Cardiac Arrest.

Each year, approximately half a million people suffer out-of-hospital cardiac arrest (CA) in Europe: The majority die. Survival after CA varies greatly between regions and countries. The authors give an overview of the important elements necessary to promote improved survival after CA as a function of the chain of survival and formula for survival concepts. The chain of survival incorporates bystanders (who identify warning symptoms, call the emergency dispatch center, initiate cardiopulmonary resuscitation [CPR]), dispatchers (who identify CA, and instruct and reassure the caller), first responders (who provide high-quality CPR, early defibrillation), paramedics and other prehospital care providers (who continue high-quality CPR, and provide timely defibrillation and advanced life support, transport to CA center), and hospitals (targeted temperature management, percutaneous coronary intervention, delayed prognostication). The formula for survival concept consists of (1) medical science (international guidelines), (2) educational efficiency (e.g., low-dose, high-frequency training for lay people, first responders, and professionals; and (3) local implementation of all factors in the chain of survival and formula for survival. Survival rates after CA can be advanced through the improvement of the different factors in both the chain of survival and the formula for survival. Importantly, the neurologic outcome in the majority of CA survivors has continued to improve.

Exploring How Lay Rescuers Overcome Barriers to Provide Cardiopulmonary Resuscitation: A Qualitative Study.

BACKGROUND: Survival rates after out-of-hospital cardiac arrest (OHCA) vary considerably among regions. The chance of survival is increased significantly by lay rescuer cardiopulmonary resuscitation (CPR) before Emergency Medical Services (EMS) arrival. It is well known that for bystanders, reasons for not providing CPR when witnessing an OHCA incident may be fear and the feeling of being exposed to risk. The aim of this study was to gain a better understanding of why barriers to providing CPR are overcome. METHODS: Using a semi-structured interview guide, 10 lay rescuers were interviewed after participating in eight OHCA incidents. Qualitative content analysis was used. The lay rescuers were questioned about their CPR-knowledge, expectations, and reactions to the EMS and from others involved in the OHCA incident. They also were questioned about attitudes towards providing CPR in an OHCA incident in different contexts. RESULTS: The lay rescuers reported that they were prepared to provide CPR to anybody, anywhere. Comprehending the severity in the OHCA incident, both trained and untrained lay rescuers provided CPR. They considered CPR provision to be the expected behavior of any community citizen and the EMS to act professionally and urgently. However, when asked to imagine an OHCA in an unclear setting, they revealed hesitation about providing CPR because of risk to their own safety. CONCLUSION: Mutual trust between community citizens and towards social institutions may be reasons for overcoming barriers in providing CPR by lay rescuers. A normative obligation to act, regardless of CPR training and, importantly, without facing any adverse legal reactions, also seems to be an important factor behind CPR provision. Mathiesen WT , Bjørshol CA , Høyland S , Braut GS , Søreide E . Exploring how lay rescuers overcome barriers to provide cardiopulmonary resuscitation: a qualitative study. Prehosp Disaster Med. 2017;32(1):27-32.

Reactions and coping strategies in lay rescuers who have provided CPR to out-of-hospital cardiac arrest victims: a qualitative study.

OBJECTIVE: Cardiopulmonary resuscitation (CPR) provided by community citizens is of paramount importance for out-of-hospital cardiac arrest (OHCA) victims' survival. Fortunately, CPR rates by community citizens seem to be rising. However, the experience of providing CPR is rarely investigated. The aim of this study was to explore reactions and coping strategies in lay rescuers who have provided CPR to OHCA victims. METHODS, PARTICIPANTS: This is a qualitative study of 20 lay rescuers who have provided CPR to 18 OHCA victims. We used a semistructured interview guide focusing on their experiences after providing CPR. SETTING: The study was conducted in the Stavanger region of Norway, an area with very high bystander CPR rates. RESULTS: Three themes emerged from the interview analysis: concern, uncertainty and coping strategies. Providing CPR had been emotionally challenging for all lay rescuers and, for some, had consequences in terms of family and work life. Several lay rescuers experienced persistent mental recurrences of the OHCA incident and had concerns about the outcome for the cardiac arrest victim. Unknown or fatal outcomes often caused feelings of guilt and were particularly difficult to handle. Several reported the need to be acknowledged for their CPR attempts. Health-educated lay rescuers seemed to be less affected than others. A common coping strategy was confiding in close relations, preferably the health educated. However, some required professional help to cope with the OHCA incident. CONCLUSIONS: Lay rescuers experience emotional and social challenges, and some struggle to cope in life after providing CPR in OHCA incidents. Experiencing a positive patient outcome and being a health-educated lay rescuer seem to mitigate concerns. Common coping strategies are attempts to reduce uncertainty towards patient outcome and own CPR quality. Further studies are needed to determine whether an organised professional follow-up can mitigate the concerns and uncertainty of lay rescuers.

Effects of socio-emotional stressors on ventilation rate and subjective workload during simulated CPR by lay rescuers.

Several studies have documented the occurrence of high ventilation rates during cardiopulmonary resuscitation, but to date, there have been no scientific investigation of the causes of hyperventilation. The objective of the current study was to test the effects of socio-emotional stressors on lay rescuers' ventilation rate in a simulated resuscitation setting using a manikin model. A within-subjects experiment with randomized order of conditions tested lay rescuers' ventilation rate on an intubated manikin during exposure to socio-emotional stressors and during a control condition where no external stressors were present. Ventilation rates and subjective workload were significantly higher during exposure to socio-emotional stressors than during the control condition. All but one of the nine participants ventilated at a higher ventilation rate in the experimental condition. All nine participants rated the subjective workload to be higher during exposure to socio-emotional stressors. Hence, exposure to socio-emotional stressors is associated with increased ventilation rates performed by lay rescuers during simulated cardiac arrest using a manikin model. These findings might have implications for the understanding of the type of situations which hyperventilation may occur. Awareness of these situations may have implications for training of lay rescues.

Effect of socioemotional stress on the quality of cardiopulmonary resuscitation during advanced life support in a randomized manikin study.

OBJECTIVE: The aim of this study was to evaluate whether socioemotional stress affects the quality of cardiopulmonary resuscitation during advanced life support in a simulated manikin model. DESIGN: A randomized crossover trial with advanced life support performed in two different conditions, with and without exposure to socioemotional stress. SETTING: The study was conducted at the Stavanger Acute Medicine Foundation for Education and Research simulation center, Stavanger, Norway. SUBJECTS: Paramedic teams, each consisting of two paramedics and one assistant, employed at Stavanger University Hospital, Stavanger, Norway. INTERVENTIONS: A total of 19 paramedic teams performed advanced life support twice in a randomized fashion, one control condition without socioemotional stress and one experimental condition with exposure to socioemotional stress. The socioemotional stress consisted of an upset friend of the simulated patient who was a physician, spoke a foreign language, was unfamiliar with current Norwegian resuscitation guidelines, supplied irrelevant clinical information, and repeatedly made doubts about the paramedics' resuscitation efforts. Aural distractions were supplied by television and cell telephone. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the quality of cardiopulmonary resuscitation: chest compression depth, chest compression rate, time without chest compressions (no-flow ratio), and ventilation rate after endotracheal intubation. As a secondary outcome, the socioemotional stress impact was evaluated through the paramedics' subjective workload, frustration, and feeling of realism. There were no significant differences in chest compression depth (39 vs. 38 mm, p = .214), compression rate (113 vs. 116 min⁻¹, p = .065), no-flow ratio (0.15 vs. 0.15, p = .618), or ventilation rate (8.2 vs. 7.7 min⁻¹, p = .120) between the two conditions. There was a significant increase in the subjective workload, frustration, and feeling of realism when the paramedics were exposed to socioemotional stress. CONCLUSION: In this advanced life support manikin study, the presence of socioemotional stress increased the subjective workload, frustration, and feeling of realism, without affecting the quality of cardiopulmonary resuscitation.

Hospital employees improve basic life support skills and confidence with a personal resuscitation manikin and a 24-min video instruction.

INTRODUCTION: The use of a personal resuscitation manikin with video instruction is reportedly as effective as traditional instructor-led courses in teaching lay people basic life support (BLS). We applied this method to an entire hospital staff to determine its effect on their practical and self-judged BLS skills. METHODS: All 5382 employees at Stavanger University Hospital were asked to learn or refresh their BLS skills with the personal resuscitation manikin and video instruction. Prior to and nine months after training, all employees were asked to rate their BLS skills on a scale from one to five. Additionally, randomly chosen study subjects were tested for BLS skills pre-training and six months post-training during 2min of resuscitation on a manikin. RESULTS: In total, 5118 employees took part in the BLS training program. The number of correct chest compressions increased significantly from 60 (5-102) to 119 (75-150) in the pre- vs. post-training periods, respectively, P<0.01, but the number of correct MTM ventilations did not change. Self-reported BLS skills increased from 3.1 (+/-1.0) pre-training to 3.8 (+/-0.8) post-training, P=0.031. CONCLUSION: After distributing a personal resuscitation manikin with video instruction to an entire hospital staff, the median number of correctly performed chest compressions doubled and self-confidence in BLS skills improved significantly. This is a simple and less time-consuming method than instructor-led courses in preparing hospital employees in the basic handling of cardiac arrest.

Quality of chest compressions during 10min of single-rescuer basic life support with different compression: ventilation ratios in a manikin model.

INTRODUCTION: Good quality basic life support (BLS) improves outcome during cardiac arrest. As fatigue may reduce BLS performance over time we wanted to examine the quality of chest compressions in a single-rescuer scenario during prolonged BLS with different compression:ventilation ratios (C:V ratios). MATERIAL AND METHODS: Professional paramedics were asked to perform single-rescuer BLS with C:V ratios of 15:2, 30:2 and 50:2 for 10 min each in random order. A Laerdal Medical Resusci Anne Simulator with PC Skillreporting System was used for BLS quality analysis. Total number of chest compressions, compression depth and compression rate were measured and the differences between the C:V ratios were analysed with repeated measures ANOVA. For analysis of fatigue, chest compression variables for each 2-min period were analysed and compared with the first 2-min period using repeated measures ANOVA. RESULTS: Altogether 50 paramedics completed the study. The mean number of chest compressions increased significantly from 604 to 770 and 862 with C:V ratios of 15:2, 30:2 and 50:2, respectively. Chest compression rate was significantly higher with C:V ratio of 15:2 compared to 30:2 and 50:2 but was above 100 per minute for all three ratios. However, the mean chest compression depth did not change significantly between the different C:V ratios. The number of chest compressions did not change significantly with time for any of the three C:V ratios. Compression depth did decline after the first 2-min period for 30:2 and 50:2 as did compression rate for all three ratios. However all were above the guideline limits for the entire test period. CONCLUSION: Increasing the C:V ratio increases the number of chest compressions during 10 min of BLS. Compression depth and compression rate were within guideline recommendations for all three ratios. We found no decline in chest compression quality below guideline recommendations during 10 min of BLS with any of the three different C:V ratios.