Johan Israelsson

Recording signs of deterioration in acute patients : The documentation of vital signs within electronic health records in patients who suffered in-hospital cardiac arrest

Vital sign documentation is crucial to detecting patient deterioration. Little is known about the documentation of vital signs in electronic health records. This study aimed to examine documentation of vital signs in electronic health records. We examined the vital signs documented in the electronic health records of patients who had suffered an in-hospital cardiac arrest and on whom cardiopulmonary resuscitation was attempted between 2007 and 2011 (n = 228), in a 372-bed district general hospital. We assessed the completeness of vital sign data compared to VitalPAC™ Early Warning Score and the location of vital signs within the electronic health records. There was a noticeable lack of completeness of vital signs. Vital signs were fragmented through various sections of the electronic health records. The study identified serious shortfalls in the representation of vital signs in the electronic health records, with consequential threats to patient safety.

Health status and psychological distress among in-hospital cardiac arrest survivors in relation to gender

AIM To describe health status and psychological distress among in-hospital cardiac arrest (IHCA) survivors in relation to gender. METHODS This national register study consists of data from follow-up registration of IHCA survivors 3-6 months post cardiac arrest (CA) in Sweden. A questionnaire was sent to the survivors, including measurements of health status (EQ-5D-5L) and psychological distress (HADS). RESULTS Between 2013 and 2015, 594 IHCA survivors were included in the study. The median values for EQ-5D-5L index and EQ VAS among survivors were 0.78 (q1-q3=0.67-0.86) and 70 (q1-q3=50-80) respectively. The values were significantly lower (p<0.001) in women compared to men. In addition, women reported more problems than men in all dimensions of EQ-5D-5L, except self-care. A majority of the respondents reported no problems with anxiety (85.4%) and/or symptoms of depression (87.0%). Women reported significantly more problems with anxiety (p<0.001) and symptoms of depression (p<0.001) compared to men. Gender was significantly associated with poorer health status and more psychological distress. No interaction effects for gender and age were found. CONCLUSIONS Although the majority of survivors reported acceptable health status and no psychological distress, a substantial proportion reported severe problems. Women reported worse health status and more psychological distress compared to men. Therefore, a higher proportion of women may be in need of support. Health care professionals should make efforts to identify health problems among survivors and offer individualised support when needed.

Is there a difference in survival between men and women suffering in-hospital cardiac arrest?

OBJECTIVES To describe in-hospital cardiac arrest (CA) events with regard to sex and to investigate if sex is associated with survival. BACKGROUND Previous studies exploring differences between sexes are incongruent with regard to clinical outcomes. In order to provide equality and improve care, further investigations into these aspects are warranted. METHODS This registry study included 286 CAs. To investigate if sex was associated with survival, logistic regression analyses were performed. RESULTS The proportion of CA with a resuscitation attempt compared to CA without resuscitation was higher among men. There were no associations between sex and survival when controlling for previously known predictors and interaction effects. CONCLUSIONS Sex does not appear to be a predictor for survival among patients suffering CA where resuscitation is attempted. The difference regarding proportion of resuscitation attempts requires more attention. It is important to consider possible interaction effects when studying the sex perspective.

Vital sign documentation in electronic records: The development of workarounds

Workarounds are commonplace in healthcare settings. An increase in the use of electronic health records has led to an escalation of workarounds as healthcare professionals cope with systems which are inadequate for their needs. Closely related to this, the documentation of vital signs in electronic health records has been problematic. The accuracy and completeness of vital sign documentation has a direct impact on the recognition of deterioration in a patient’s condition. We examined workflow processes to identify workarounds related to vital signs in a 372-bed hospital in Sweden. In three clinical areas, a qualitative study was performed with data collected during observations and interviews and analysed through thematic content analysis. We identified paper workarounds in the form of handwritten notes and a total of eight pre-printed paper observation charts. Our results suggested that nurses created workarounds to allow a smooth workflow and ensure patients safety.

Characteristics and outcome among 14,933 adult cases of in-hospital cardiac arrest: A nationwide study with the emphasis on gender and age

Aim To investigate characteristics and outcome among patients suffering in‐hospital cardiac arrest (IHCA) with the emphasis on gender and age. Methods Using the Swedish Register of Cardiopulmonary Resuscitation, we analyzed associations between gender, age and co‐morbidities, etiology, management, 30‐day survival and cerebral function among survivors in 14,933 cases of IHCA. Age was divided into three ordered categories: young (18–49 years), middle‐aged (50–64 years) and older (65 years and above). Comparisons between men and women were age adjusted. Results The mean age was 72.7 years and women were significantly older than men. Renal dysfunction was the most prevalent co‐morbidity. Myocardial infarction/ischemia was the most common condition preceding IHCA, with men having 27% higher odds of having MI as the underlying etiology. A shockable rhythm was found in 31.8% of patients, with men having 52% higher odds of being found in VT/VF. After adjusting for various confounders, it was found that men had a 10% lower chance than women of surviving to 30 days. Older individuals were managed less aggressively than younger patients. Increasing age was associated with lower 30‐day survival but not with poorer cerebral function among survivors. Conclusion When adjusting for various confounders, it was found that men had a 10% lower chance than women of surviving to 30 days after in‐hospital cardiac arrest. Older individuals were managed less aggressively than younger patients, despite a lower chance of survival. Higher age was, however, not associated with poorer cerebral function among survivors.

Sensitivity and specificity of two different automated external defibrillators

AIM The aim was to investigate the clinical performance of two different types of automated external defibrillators (AEDs). METHODS Three investigators reviewed 2938 rhythm analyses performed by AEDs in 240 consecutive patients (median age 72, q1-q3=62-83) who had suffered cardiac arrest between January 2011 and March 2015. Two different AEDs were used (AED A n=105, AED B n=135) in-hospital (n=91) and out-of-hospital (n=149). RESULTS Among 194 shockable rhythms, 17 (8.8%) were not recognized by AED A, while AED B recognized 100% (n=135) of shockable episodes (sensitivity 91.2 vs 100%, p<0.01). In AED A, 8 (47.1%) of these episodes were judged to be algorithm errors while 9 (52.9%) were caused by external artifacts. Among 1039 non-shockable rhythms, AED A recommended shock in 11 (1.0%), while AED B recommended shock in 63 (4.1%) of 1523 episodes (specificity 98.9 vs 95.9, p<0.001). In AED A, 2 (18.2%) of these episodes were judged to be algorithm errors (AED B, n=40, 63.5%), while 9 (81.8%) were caused by external artifacts (AED B, n=23, 36.5%). CONCLUSIONS There were significant differences in sensitivity and specificity between the two different AEDs. A higher sensitivity of AED B was associated with a lower specificity while a higher specificity of AED A was associated with a lower sensitivity. AED manufacturers should work to improve the algorithms. In addition, AED use should always be reviewed with a routine for giving feedback, and medical personnel should be aware of the specific strengths and shortcomings of the device they are using.

Quality of chest compressions by healthcare professionals using real-time audiovisual feedback during in-hospital cardiopulmonary resuscitation:

Introduction: A high quality of chest compressions, e.g. sufficient depth (5–6 cm) and rate (100–120 per min), has been associated with survival. The patient’s underlay affects chest compression depth. Depth and rate can be assessed by feedback systems to guide rescuers during cardiopulmonary resuscitation. Aim: The purpose of this study was to describe the quality of chest compressions by healthcare professionals using real-time audiovisual feedback during in-hospital cardiopulmonary resuscitation. Method: An observational descriptive study was performed including 63 cardiac arrest events with a resuscitation attempt. Data files were recorded by Zoll AED Pro, and reviewed by RescueNet Code Review software. The events were analysed according to depth, rate, quality of chest compressions and underlay. Results: Across events, 12.7% (median) of the compressions had a depth of 5–6 cm. Compression depth of >6 cm was measured in 70.1% (median). The underlay could be identified from the electronic patient records in 54 events. The median compression depth was 4.5 cm (floor) and 6.7 cm (mattress). Across events, 57.5% (median) of the compressions were performed with a median frequency of 100–120 compressions/min and the most common problem was a compression rate of <100 (median=22.3%). Conclusions: Chest compression quality was poor according to the feedback system. However, the distribution of compression depth with regard to underlay points towards overestimation of depth when treating patients on a mattress. Audiovisual feedback devices ought to be further developed. Healthcare professionals need to be aware of the strengths and weaknesses of their devices.

Test cases: in-hospital, scenario-based cardiopulmonary resuscitation training.

encounters. The piloted case required residents to obtain informed consent for a lumbar puncture. No additional time was provided for the encounter. Evaluation of results and impact Training the SPs to portray the case accurately, rate the residents using our standard communication scale and provide effective feedback did not require utilising the additional training time allotted because ASL interpretation occurred simultaneously rather than being delivered in alternation with the speaker as in other language interpretations. The primary training challenge involved reviewing the pre-existing videos because it was difficult for the SPs to simultaneously observe the video and the interpreter. Each of the deaf SPs encountered two neurology residents. Two of the four residents were female; three were in the third year of training and one was in the second year. All residents had prior experience working with an interpreter with hearing patients who did not speak English; only one had previously worked with a deaf patient. We observed several errors typical of working with interpreters. None of the residents established whether the patient and interpreter were related and they often used medical terminology without explanation for the interpreter. Working with an ASL interpreter was unique in that the deaf patient looked at the interpreter while the doctor was speaking, making it difficult for the doctor to maintain eye contact. The SPs were able to assess and complete all items of the CIS checklist and rating scale. Residents agreed that verbal feedback was helpful. Both SPs and residents recommended longer encounters and longer feedback sessions. Training deaf SPs is feasible and has the potential to help residents improve communication, become cross-culturally sensitive and provide effective health care for deaf patients.

Factors associated with health-related quality of life among cardiac arrest survivors treated with an implantable cardioverter-defibrillator

AIM To explore factors associated with health-related quality of life (HRQoL) among cardiac arrest (CA) survivors treated with an implantable cardioverter-defibrillator (ICD) in relation to gender, and to compare their HRQoL with a general population. METHODS This cross-sectional study included 990 adults treated with an ICD after suffering CA. All participants received a questionnaire including demographics, comorbidities and instruments to measure HRQoL (EQ-5D-3L and HADS), ICD-related concerns (ICDC), perceived control (CAS), and type D personality (DS-14). HRQoL (EQ-5D-3L) was compared to a general Swedish population, matched for age and gender. Linear regression analyses were used to explore factors associated with HRQoL. RESULTS The CA survivors reported better HRQoL in EQ index and less pain/discomfort compared to the general population (p < 0.001). In contrast, they reported more problems in mobility and usual activities (p < 0.01). Problems with anxiety and depression were reported by 15.5% and 7.4% respectively. The following factors were independently associated with all aspects of worse HRQoL: being unemployed, suffering more comorbidity, perceiving less control, and having a type D personality. Further, being female and suffering ICD-related concerns were independently associated with worse HRQoL in three of the four final regression models. CONCLUSIONS This extensive population-based study showed that most CA survivors living with an ICD rate their HRQoL as acceptable. In addition, their HRQoL is similar to a general population. Women reported worse HRQoL compared to men. Several factors associated with HRQoL were identified, and might be used when screening patients for health problems and when developing health promoting interventions.

Sensitivity and specificity of two different automated external defibrillators used in-hospital and out-of-hospital

Sensitivity and specificity of two different automated external defibrillators (AED) used in-hospital and out-of-hospital