An Initiative Using Simulation to Aid in Retention of Advanced Cardiac Life Support Knowledge and Skills in an Emergency Department Nurse Residency Program.

INTRODUCTION: Cardiac arrest is the most urgent type of emergency, and favorable outcomes are best achieved by early resuscitation. Advanced Cardiac Life Support (ACLS) certification enables nurses to provide care to patients who are at a high risk of life-threatening emergencies. OBJECTIVE: The objective of this quality improvement project was to explore the retention of knowledge and skills of 20 graduate nurses who participated in a nurse residency program using an ACLS simulation-based learning experience (SBLE) at 2 and 8 weeks post completion of an ACLS provider course. METHODS: A pretest-posttest design was used with 2 emergency department graduate nurse cohorts who participated in an SBLE focused on ACLS components at 2 and 8 weeks after attending the ACLS provider course. Simulation-based learning experiences were videotaped, and outcome measures (ie, time to shock) were measured in seconds. The nurses completed the ACLS written test before and after the SBLE. RESULTS: Most ACLS outcomes improved after SBLE except time to shock. Pretest-posttest ACLS average scores decreased from 93.5% to 77.8% (first cohort) and from 94.5% to 86.7% (second cohort). DISCUSSION: Simulation-based learning experience may be an important adjunct instructing method for teaching new graduates ACLS skills.

Relación entre la autopercepción y autoeficacia para el desarrollo de competencias en soporte vital en entornos de simulación clínica de alta fidelidad / Relationship between self-perception and self-efficacy for the development of competencies in Vital Life Support in high-fidelity clinical simulation environments

OBJETIVO: Analizar si existe relación entre la autopercepción y la autoeficacia para el desarrollo de competencias asociadas al cuidado de paciente crítico en un entorno clínico de simulación de alta fidelidad, en la formación de estudiantes de enfermería en soporte vital. MÉTODO: Estudio cuasi-experimental realizado en el curso 2014-2015, en 2 grupos de alumnos del grado de enfermería con medición pre-post test, sometidos a la misma experiencia de simulación de paciente crítico con evolución posible a parada cardiaca. Se utilizó como marco teórico la educación en simulación en enfermería, la autopercepción y la autoeficacia, así como las últimas recomendaciones del Consejo europeo en resucitación. RESULTADOS: En ambos grupos se observó un aumento significativo de la autopercepción para el desarrollo de competencias asociadas a una situación crítica con variaciones entre ambos grupos en relación con la autopercepción y la autoconfianza. CONCLUSIONES: Los resultados nos permiten recomendar la simulación clínica para la formación de estudiantes en soporte vital, al aumentar de manera significativa su nivel de autopercepción para el desarrollo de competencias asociadas a los cuidados críticos, y establecer relaciones positivas entre la autopercepción y la autoconfianza del estudiante

OBJECTIVE: To determine if there is a correlation between self-perception and self- efficacy in the development of learning abilities associated with the care of the critically ill patient in a Clinical Environment of High Fidelity Simulation, as part of the training for nursing students in the field of Life Support. METHOD: Quasi-experimental study carried out in academic year 2014-2015 with two groups of Nursing Degree students, and applying pre/post measurement tests. The students were subjected to the same simulation experience, that of a critical patient with a possible progression to cardiac arrest. Simulation training, self-perception, and self-efficacy were used as theoretical framework, as well as the latest recommendations by European Resuscitation Council. RESULTS: A significant increase in self-perception for the development of competences associated with a critical situation was observed in both groups. As for self-perception and self-efficacy, some variations were found between the groups. CONCLUSIONS: The results found allow us to recommend clinical simulation for the training of students in critically ill patients, since there is a significant increase in the level of self-perception for the development of competences associated with critical care. Likewise, clinical simulation provides a positive link between self-perception and self-confidence in the students

Soporte vital avanzado enfermero: ¿una realidad? / Advanced life support nursing: what is the current situation?

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Atuação da equipe de enfermagem no atendimento à parada cardiorrespiratória cerebral / Rendimiento del personal de enfermería en la asistencia al paro cardiopulmonar cerebral / Nursing team’s performance in meeting the cerebral cardiopulmonary arrest

O estudo tem como objetivo analisar o conhecimento da equipe de enfermagem diante do reconhecimento de uma PCRC e sobre a reanimação cardiopulmonar cerebral (RCPC). Trata-se de um estudo transversal com abordagem quantitativa desenvolvido em um Hospital da rede pública localizado no nordeste brasileiro. A coleta de dados ocorreu mediante um questionário semi-estruturado com 110 profissionais de nível médio e superior da enfermagem. Aprovado pelo Comitê de Ética em Pesquisa CAAE: 15504613.2.0000.5537. Em relação ao reconhecimento da PCRC, (81,8%) dos profissionais identificaram de forma apropiada; (80%) responderam de forma correta acerca da sequência do SBV; (77,2%) acertaram a relação compressão/ventilação; (61,8%) sabem da necessidade de priorizar compressões torácicas; (51,8%) responderam de forma adequada sobre a postura corporal para realização das compressões; somente (40%) teve êxito nas respostas quando questionado sobre a profundidade e frequência das compressões; (60%) mostraram conhecer os principais ritmos cardíacos presentes numa PCRC. A equipe de enfermagem analisada apresentou conhecimentos ainda deficientes acerca das mudanças das Diretrizes da American Heart Association de 2010, dessa forma, existe a necessidade urgente de capacitação para que reduzam as falhas e atraso que comprometem um atendimento de qualidade (AU)

Este estudio tiene como objetivo analizar el conocimiento del personal sobre el reconocimiento de un paro cardiopulmonar cerebral (PCRC) y reanimación cardiopulmonar cerebral (RCPC) de enfermería. Se trata de un estudio transversal con enfoque cuantitativo que se realizó en un Hospital público situado en el noreste de Brasil. La recolección de datos se produjo a través de un cuestionario semiestructurado con 110 profesionales de nivel medio alto de enfermería. Aprobado por el Comité de ética en investigación CAAE: 15504613.2.0000.5537. En relación con el reconocimiento de PCRC, (81.8%) de los profesionales han identificado de forma apropiada; (80%) respondieron correctamente sobre la secuencia del SBV; (77,2%) tiene la relación de compresión y ventilación; (61,8%) sabe acerca de la necesidad de priorizar las compresiones de pecho; (51.8 %) respondido adecuadamente en la postura del cuerpo para la realización de las compresiones; sólo (40%) tuvo éxito en sus respuestas cuando se le preguntó acerca de la profundidad y la frecuencia de las compresiones. El personal de enfermería analizados tenía conocimiento aún deficiente sobre los cambios de las pautas de la American Heart Association de 2010 por lo tanto existe la necesidad de formación urgente que reducen las fallas y retrasos que comprometen una atención de calidad (AU)

The study aims to analyze the knowledge of nursing staff on the recognition of a cerebral cardiopulmonary arrest (CCPA) and about the cerebral cardiopulmonary resuscitation (CCPR). This is a cross-sectional study with quantitative approach developed in a public Hospital located in northeastern Brazil. Data collection occurred through a semi-structured questionnaire with 110 professionals of medium-high level of nursing. Approved by the Research Ethics Committee CAAE: 15504613.2.0000.5537. In relation to the recognition of PCRC, (81.8%) of professionals have identified appropriate form; (80%) answered correctly about the sequence of the CPR; (77.2%)got the compression/ventilation ratio; (61.8%) know about the need prioritizing chest compressions;(51.8%) responded adequately on body posture for realization of the compressions; only (40%) succeeded in their responses when asked about the depth and frequency of compressions. The nursing staff analyzed presented knowledge still disabled on the changes of the guidelines of the American Heart Association of 2010 thus exists the need urgent training that reduce the failures and delays that compromise a quality car (AU)

Pharmacotherapy of pediatric advanced life support and toxicological emergencies.

Guidelines for pediatric advanced life support have been available for nearly a quarter of a century. Recommendations for the pharmacological management of pediatric cardiac arrest have changed over these years. Several important differences have been observed between adult advanced cardiac life support and pediatric advanced life support that must be recognized when children require resuscitation, such as the cause of the arrest, age-specific monitoring parameters, weight-based medication dosing, and obstacles in obtaining venous access. To make matters more complicated, differences also exist across neonatal and pediatric age spectrums. In addition, some toxicological emergencies commonly occurring in children require pharmacological management with agents that have a unique mechanism of action for cardiac support.

Conocimiento enfermero sobre hipotermia inducida tras parada cardiorrespiratoria: revisión bibliográfica / Nursing knowledge about hypothermia induced after cardiopulmonary arrest: literature review

Este trabajo pretende realizar una revisión de la evidencia científica actual sobre la hipotermia (HT) terapéutica inducida tras parada cardiorrespiratoria (PC). Examinar la literatura publicada; el conocimiento enfermero existente; y la búsqueda del rol propio de Enfermería. Antecedentes La PC es una situación sanitaria problemática que lleva asociada una alta mortalidad. Gracias a las maniobras de reanimación cardiopulmonar (RCP) han aumentado los pacientes que recuperan la circulación espontánea; en cambio, la mortalidad en las Unidades de Cuidados Intensivos (UCI), derivada de los daños neurológicos producidos, sigue siendo muy alta. La HT terapéutica inducida se define como un elemento protector frente al daño neurológico consecuente de la PC, y las maniobras de RCP; y a pesar de las recomendaciones sobre su utilización dentro del manejo del síndrome posparada, existe poca rigurosidad sobre su uso, escasa estandarización enfermera, y falta de protocolos en nuestras UCI. Estrategia de búsqueda Las bases de datos a las que se accede son: Medline, Pubmed, Ocenet Salud, Cochrane Library Plus, Cuiden, Scielo, y las plataformas electrónicas Elsevier, OVID y ProQuest. Las siguientes palabras clave se utilizaron para iniciar la búsqueda: Hypothermia, Induced, Heart Arrest, Nursing. Criterios de inclusión y exclusión Solo evidencias publicadas desde el año 2005, sin importar el idioma de salida, priorizando aquellos trabajos con participación enfermera. Conclusiones esta trabajo deja patente la evidencia del uso de HT inducida tras PC; y los conocimientos y literatura necesaria para que Enfermería interprete un rol propio, e implemente protocolos estandarizados en nuestras UCI en relación (AU)

This paper aims to conduct a review of current scientific evidence on therapeutic hypothermia (TH) induced after cardiac arrest (CA).To examine the published literature; existing nursing knowledge; and the pursuit of the proper role of nursing. Background CA is a problematic health status with a high associated mortality rate. Cardiopulmonary resuscitation (CPR) techniques have increased the number of patients who recover spontaneous circulation, whereas, mortality in intensive care units (ICU) arising from the neurological damage produced, remains very high. Induced TH is defined as a protective factor against neurological damage resulting from the CA and CPR, but despite the recommendations on its use in the management of post-cardiac arrest syndrome, there is little rigour in its use, little nurse standardisation, and a lack of protocols in our ICU .Search strategy The databases which can be accessed are: Medline, Pubmed, Ocenet Health, Cochrane Library Plus, Cuiden, Scielo, and electronic platforms Elsevier, OVID and ProQuest. The following keywords were used to start the search: "Hypothermia, Induced", "Heart Arrest", "Nursing". Inclusion and exclusion criteria: only evidence published since 2005, regardless of the output language, focusing on those works involving nursing. Conclusions This work shows clear evidence of the use of TH induced after CA, and the literature and knowledge required for nursing to interpret their own role, and to introduce standardised protocols for ICUs (AU)

Assessment of CPR-D skills of nursing students in two institutions: reality versus recommendations in the guidelines.

Significant differences in basic life support skills including cardiopulmonary resuscitation and defibrillation (CPR-D) were detected when nurses working in one Finnish and one Swedish hospital were tested using an Objective Structured Clinical Examination (OSCE). The purpose of this study was to use OSCE test in assessing guideline based CPR-D skills of newly qualified nurses. The CPR-D skills of newly qualified registered nurses studying in Halmstad University (n = 30), Sweden, Helsinki Metropolia University of Applied Sciences (n = 30), and Finland were assessed using an OSCE which was built up with a case of cardiac arrest with ventricular fibrillation as the initial rhythm. The Angoff average, 32.47, was calculated as cutoff point to pass the test. Forty-seven percent of the students in the Swedish group (mean score 32.47/49, range 26-39, SD 3.76) and 13% of the students in the Finnish group (mean score 23.80/49, range 13-35, SD 4.32) passed the OSCE (P<0.0001), the cutoff point being 32.47. Performance grade for the Swedish group was 2.9/5.0 and for the Finnish group 2.1/5.0 (P<0.0001). Good nontechnical skills correlated with high grading of the clinical skills. In conclusion, CPR-D skills of the newly qualified nurses in both the institutes were clearly under par and were not adequate according to the resuscitation guidelines. Current style of teaching is unlikely to result in students being able to perform adequate CPR-D. Standardized testing would help in controlling the quality of learning.

Educação Permanente em SBV e SAVC: impacto no conhecimento dos profissionais de enfermagem / Permanent Education in BLS and ACLS: impact on the knowledge of nursing professionals / Educación permanente en SBV y SAV: impacto en el conocimiento de los profesionales de enfermería

Fundamento: O conhecimento teórico e as habilidades práticas das equipes de Suporte Básico de Vida (SBV) e Suporte Avançado de Vida (SAV) estão entre os determinantes mais importantes das taxas de sucesso em reanimação cardiopulmonar. Objetivo: Avaliar o impacto de um programa permanente de treinamento em SBV e SAV no conhecimento dos profissionais de enfermagem. Método: Estudo de corte transversal. A população foi composta por profissionais de enfermagem de um hospital de nível terciário. Foram realizadas avaliações antes e após o treinamento. Abordaram-se pontos críticos das diretrizes do International Liaison Committee on Resuscitation (ILCOR). Resultados: Foram avaliados 213 profissionais (76 enfermeiros, 35,7 por cento; 38 auxiliares, 17,8 por cento; e 99 técnicos, 46,7 por cento). As médias na avaliação pré-curso foram estatisticamente diferentes (p<0,001) entre auxiliares (3,25), técnicos (3,96) e enfermeiros (4,69). Os profissionais solteiros e sem filhos apresentaram desempenho significativamente superior ao dos casados e com filhos (p=0,02 e 0,004 respectivamente). O nível de conhecimento pré-treinamento foi inversamente proporcional ao tempo transcorrido desde a conclusão da graduação ou curso técnico. As maiores deficiências foram relacionadas à abordagem inicial das vias aéreas, aos cuidados pós-ressuscitação e à técnica de massagem cardíaca externa. A média geral pós-curso foi 7,26. Os auxiliares alcançaram um desempenho de 131,2 por cento, os técnicos de 78,9 por cento e os enfermeiros de 85 por cento, sem diferença estatisticamente significante (p=0,43). Conclusão: O programa de treinamento permanente em SBV e SAV resultou em importante incremento no nível de conhecimento dos profissionais de enfermagem.

Background: The theoretical knowledge and practical skills of the Basic Life Support (BLS) and the Advanced Life Support (ALS) are among the most important determining factors of the cardiopulmonary reanimation success rates. Objective: Assess the impact of a permanent training program in BLS and ALS on the knowledge of nursing professionals. Method: Cross-sectional study. Population was made of nursing professionals of a tertiary level hospital. Assessments were carried out before and after training. The critical points of the International Liaison Committee on Resuscitation (ILCOR) analysis were addressed. Results: 213 professionals were assessed (76 nurses, 35.7 percent; 38 assistants, 17.8 percent; and 99 technicians, 46.7 percent). Pre-course assessment average grades were statistically different (p<0.001) among assistants (3.25), technicians (3.96) and nurses (4.69). Single professional without kids showed performance significantly superior to married professional with kids (p=0.02 and 0.004 respectively). Pre-training level of knowledge was inversely proportional to the time elapsed since the completion of undergraduate course or technical course. Main deficiencies were related to the initial approach of airways, to post-resuscitation cares and to the external cardiac massage technique. The post-course general average grade was 7.26. Assistants achieved a performance of 131.2 percent, technicians, of 78.9 percent and the nurses, of 85 percent, with no significant statistic difference (p=0.43). Conclusion: The permanent training program in BLS and ALS resulted in important increment in the level of knowledge of nursing professionals.

Fundamento: El conocimiento teórico y las habilidades prácticas de los equipos de Soporte Básico de Vida (SBV) y Soporte Avanzado de Vida (SAV) están entre los determinantes más importantes de los índices de éxito en reanimación cardiopulmonar. Objetivo: Evaluar el impacto de un programa permanente de entrenamiento en SBV y SAV en el conocimiento de los profesionales de enfermería. Método: Estudio de corte transversal. La población estaba compuesta por profesionales de enfermería de un hospital de nivel terciario. Se realizaron evaluaciones antes y después del entrenamiento. Se abordaron puntos críticos de las directrices del International Liaison Committee on Resuscitation (ILCOR). Resultados: Se evaluaron 213 profesionales (76 enfermeros, 35,7 por ciento, 38 auxiliares, 17,8 por ciento y 99 técnicos, 46,7 por ciento). Los promedios en la evaluación previa al curso fueron estadísticamente diferentes (p<0,001) entre auxiliares (3,25), técnicos (3,96) y enfermeros (4,69). Los profesionales solteros y sin hijos presentaron desempeño significativamente superior al de los casados y con hijos (p=0,02 y 0,004 respectivamente). El nivel de conocimiento previo al entrenamiento fue inversamente proporcional al tiempo transcurrido desde la conclusión de la graduación o curso técnico. Las mayores deficiencias estaban relacionadas al abordaje inicial de las vías aéreas, a los cuidados post resucitación y a la técnica de masaje cardíaco externo. El promedio general después del curso fue 7,26. Los auxiliares alcanzaron un desempeño del 131,2 por ciento, los técnicos del 78,9 por ciento y los enfermeros del 85 por ciento, sin diferencia estadísticamente significativa (p=0,43). Conclusión: El programa de entrenamiento permanente en SBV y SAV resultó en un importante incremento en el nivel de conocimiento de los profesionales de enfermería.

Assessing advanced life support (ALS) competence: Victorian practices.

Advanced life support (ALS) assessments are performed to assess nurses' abilities to recognize cardiac arrest events, and appropriately manage patients according to resuscitation guidelines. Although there is evidence for conducting assessments after initial ALS education, there is little evidence to guide educators about ongoing assessments in terms of methods, format and frequency. The aim of this study was to determine methods used by educators to assess ALS skills and knowledge for nurses in Victorian intensive care units. This descriptive study used telephone interviews to collect data. Data were analysed using content analysis. Twenty intensive care educators participated in this study. Thirteen educators (65%) were employed in public hospitals, and 7 educators (35%) worked in private hospitals across 12 Level 3 (60%) and 8 Level 2 (40%) intensive care units. Results showed all educators used scenarios to assess ALS skills, with 12 educators (60%) including an additional theoretical test. There was variability in ALS assessment frequency, assessment timing in relation to initial/ongoing education, person performing the assessment, and the assessor/participant ratio. Nineteen educators (95%) reported ALS skill competency assessments occurred annually; 1 educator (5%) reported assessments occurred every 2 years. Assessments were conducted during a designated month (n=10), numerous times throughout the year (n=8), or on nurses' employment anniversaries (n=2). All educators reported many nurses avoided undertaking assessments. Variability in ongoing ALS assessment methods was evident in Victorian intensive care units with some units applying evidence-based practices. Consideration should be given to the purposes and methods of conducting annual ALS assessments to ensure resources and strategies are directed appropriately. To encourage nurses to retain ALS skills and knowledge, regular practices are recommended as an alternative to assessments. However, further research is required to support this notion.

Permanent Education in BLS and ACLS: impact on the knowledge of nursing professionals.

BACKGROUND: The theoretical knowledge and practical skills of the Basic Life Support (BLS) and the Advanced Life Support (ALS) are among the most important determining factors of the cardiopulmonary reanimation success rates. OBJECTIVE: Assess the impact of a permanent training program in BLS and ALS on the knowledge of nursing professionals. METHOD: Cross-sectional study. Population was made of nursing professionals of a tertiary level hospital. Assessments were carried out before and after training. The critical points of the International Liaison Committee on Resuscitation (ILCOR) analysis were addressed. RESULTS: 213 professionals were assessed (76 nurses, 35.7%; 38 assistants, 17.8%; and 99 technicians, 46.7%). Pre-course assessment average grades were statistically different (p<0.001) among assistants (3.25), technicians (3.96) and nurses (4.69). Single professional without kids showed performance significantly superior to married professional with kids (p=0.02 and 0.004 respectively). Pre-training level of knowledge was inversely proportional to the time elapsed since the completion of undergraduate course or technical course. Main deficiencies were related to the initial approach of airways, to post-resuscitation cares and to the external cardiac massage technique. The post-course general average grade was 7.26. Assistants achieved a performance of 131.2%, technicians, of 78.9% and the nurses, of 85%, with no significant statistic difference (p=0.43). CONCLUSION: The permanent training program in BLS and ALS resulted in important increment in the level of knowledge of nursing professionals.

The effect of high-fidelity simulation on educational outcomes in an advanced cardiovascular life support course.

INTRODUCTION: The use of high-fidelity simulation has been studied in many healthcare education areas. However, the use of this instructional technology in the American Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS) course has not been extensively reported, despite this program being one of the most widely taught standardized medical courses in the United States. METHODS: This study examined high-fidelity versus low-fidelity simulation in the context of an AHA ACLS course to determine subjects' educational outcomes as judged by expert raters reviewing videos of subjects performing a simulated cardiac arrest event immediately after the conclusion of the course. A purposeful sample of 34 subjects was enrolled in one of two ACLS classes. One class used high-fidelity simulation (n = 16), whereas the other used low-fidelity simulation (n = 18). RESULTS: The high-fidelity simulation group had a higher overall mean rank score on expert rater video review (M = 59.55 versus M = 44.34). This difference reached a level of statistical significance (P = 0.010, z = -2.592). On item level analysis of the instrument, 9 of 14 items reached levels of significance (P < 0.05). CONCLUSIONS: Expert raters judged students in a high-fidelity simulation-based AHA ACLS course as more competent than students in a low-fidelity course. On item level analysis, items focused on manual tasks or actions in the first 1 to 2 minutes of the cardiac arrest event were more likely to be nonsignificant. As the scenario grew longer and more complex, expert rater scores of the high-fidelity trained team leaders' confidence, knowledge, and treatment decisions were higher than the low-fidelity team leaders' score at a statistically significant level.

Portable rapid response extracorporeal life support: a center's 20-year experience with a registered nurse-run program.

If advanced cardiac life support therapy fails to revive a patient, extracorporeal life support (ECLS) becomes a critical bridge that maintains total systemic circulation and oxygenation during cardiac arrest or severe respiratory failure and allows time to establish a treatment plan. Improved patient outcomes depend on a shorter time period from the start of advanced cardiac life support to the initiation of ECLS. An in-house critical care nurse response team facilitates rapid initiation of ECLS, often in less than 20 minutes, at any time in any area of the hospital. Since 1986, Sharp Memorial Hospital has placed 176 patients on ECLS, using a registered nurse team with a survival rate greater than 30 days of 27.7%. The system used for rapid and mobile initiation of ECLS maintains perfusion to the vital organs via a centrifugal flow pump, using a hollow-fiber membrane oxygenator and percutaneous cannulas. Team members prime the system while the ECLS-trained first-response physicians place cannulae. All elements of program development, team education, and ongoing program maintenance are critical to successful outcomes for patients.

Desfibrilador externo semiautomático (DESA). Actualización en su manejo / Update in the use of a semiautomatic external defibrillator

La supervivencia depende de la rapidez con que se aplique al paciente el primer choque eléctrico desde el inicio de la arritmia mortal, por ello se debe recomendar y divulgar el desfibrilador externo semiautomático (DESA)(AU)

Survival depends on the speed by which one applies the first electric shock to a patient after the onset of a deadly arrhythmia; therefore, the authors recommend and publicize the use of a Semiautomatic External Defibrillator(AU)

Should critical care nurses be ACLS-trained?

The aim of resuscitation is to sustain life with intact neurological functioning and the same quality of life previously experienced by the patient. Advanced cardiac life support (ACLS) was designed to achieve this aim. However the requirement for ACLS training for critical care nurses working in Canadian critical care units is inconsistent across the country. The purposes of this article are to explore the evidence surrounding ACLS training for critical care nurses and its impact on resuscitation outcomes, and to review the evidence surrounding ACLS knowledge and skill degradation with strategies to support code blue team efficiency for an effective resuscitation. Using the search terms ACLS training, resuscitation, critical care, and nursing, two databases, CINAHL and MEDLINE, were used. The evidence supports the need for ACLS training for critical care nurses. The evidence also supports organized ongoing refresher courses, multidisciplinary mock code blue practice using technologically advanced simulator mannequins, and videotaped reviews to prevent knowledge and skill degradation for effective resuscitation efforts.