Kasper Glerup Lauridsen

Organisation of in-hospital cardiac arrest teams - A nationwide study

BACKGROUND In-hospital cardiac arrests are treated by a team of health care providers. Improving team performance may increase survival. Currently, no international standards for cardiac arrest teams exist in terms of member composition and allocation of tasks. AIM To describe the composition of in-hospital cardiac arrest teams and review pre-arrest allocation of tasks. METHODS A nationwide cross-sectional study was performed. Data on cardiac arrest teams and pre-arrest allocation of tasks were collected from protocols on resuscitation required for hospital accreditation in Denmark. Additional data were collected through telephone interviews and email correspondence. Psychiatric hospitals and hospitals serving outpatients only were excluded. RESULTS Data on the cardiac arrest team were available from 44 of 47 hospitals. The median team size was 5 (25th percentile; 75th percentile: 4; 6) members. Teams included a nurse anaesthetist (100%), a medical house officer (82%), an orderly (73%), an anaesthesiology house officer (64%) and a medical assistant (20%). Less likely to participate was a cardiology house officer (23%) or a cardiology specialist registrar (5%). Overall, a specialist registrar was represented on 20% of teams and 20% of cardiac arrest teams had a different team composition during nights and weekends. In total, 41% of teams did not define a team leader pre-arrest, and the majority of the teams did not define the tasks of the remaining team members. CONCLUSION In Denmark, there are major differences among cardiac arrest teams. This includes team size, profession of team members, medical specialty and seniority of the physicians. Nearly half of the hospitals do not define a cardiac arrest team leader and the majority do not define the tasks of the remaining team members.

Cardioversion Efficacy Using Pulsed Biphasic or Biphasic Truncated Exponential Waveforms: A Randomized Clinical Trial

Background Several different defibrillators are currently used for cardioversion and defibrillation of cardiac arrhythmias. The efficacy of a novel pulsed biphasic (PB) waveform has not been compared to other biphasic waveforms. Accordingly, this study aims to compare the efficacy and safety of PB shocks with biphasic truncated exponential (BTE) shocks in patients undergoing cardioversion of atrial fibrillation or ‐flutter. Methods and Results This prospective, randomized study included patients admitted for elective direct current cardioversion. Patients were randomized to receive cardioversion using either PB or BTE shocks. We used escalating shocks until sinus rhythm was obtained or to a maximum of 4 shocks. Patients randomized to PB shocks received 90, 120, 150, and 200 J and patients randomized to BTE shocks received 100, 150, 200, and 250 J, as recommended by the manufacturers. In total, 69 patients (51%) received PB shocks and 65 patients (49%) BTE shocks. Successful cardioversion, defined as sinus rhythm 4 hours after cardioversion, was achieved in 43 patients (62%) using PB shocks and in 56 patients (86%) using BTE shocks; ratio 1.4 (95% CI 1.1–1.7) (P=0.002). There was no difference in safety (ie, myocardial injury judged by changes in high‐sensitive troponin I levels; ratio 1.1) (95% CI 1.0–1.3), P=0.15. The study was terminated prematurely because of an adverse event. Conclusions Cardioversion using a BTE waveform was more effective when compared with a PB waveform. There was no difference in safety between the 2 waveforms, as judged by changes in troponin I levels. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02317029.

A call for 2222 in European hospitals-A reply to letter by Dr. Whitaker.

We have with great interest read the letter by Dr. Whitaker on a tandardized cardiac arrest call telephone number for all European ospitals.1 A standardized telephone number to summon the cariac arrest team is suggested to improve patient safety. However, he possible impact of standardizing the hospital cardiac arrest elephone number on hospital staff awareness is unknown. Recently, we conducted a nationwide survey in all public Dansh hospitals using telephone interviews with physicians on cardiac rrest teams. Physicians were inquired about the cardiac arrest telehone number in their hospital. Subsequently, each hospital was ontacted to validate the cardiac arrest telephone number. In Denmark, cardiac arrest teams generally consist of one or ore physicians, nurses and orderlies.2 We interviewed 90 physiians (response rate: 100%) in 43 hospitals. One physician was xcluded from data analysis because the hospital in which this hysician worked did not have a cardiac arrest telephone numer. Overall, 30% of physicians did not know the cardiac arrest elephone number. Moreover, 25% stated an incorrect number hile 45% stated the correct number. In Denmark, 26 different ardiac arrest telephone numbers were used in 41 hospitals (of 2), whereas 1 hospital used several different numbers specific for ach department. In one Danish region, all hospitals (n = 11, physiians interviewed: 23) used one number (2222). Interestingly, more hysicians (78%) in this region were able to state the correct cardiac rrest telephone number compared with 33% in regions not using a tandardized number (p < 0.001, chi squared test). Our survey has a umber of limitations; the survey included only cardiac arrest team hysicians, while calling the cardiac arrest team is often performed y ward personnel. The awareness of the cardiac arrest telephone umber may be lower in an “unselected” group of hospital staff. In ddition, the survey includes a limited sample size. Nonetheless, ur data suggest that standardizing the cardiac arrest telephone umber may improve awareness. Our findings also indicate that standardizing cardiac arrest telehone numbers are under-prioritized. Barriers for implementing a tandardized telephone number may include lacking knowledge of ecommendations,3,4 technical and financial issues and local poliics. The financial costs of standardization are unknown and may ar exceed the estimated 7.500 Euros per hospital.4 Careful analysis f the financial implications of standardization is needed. Hospial administrators and opinion makers may argue that the clinical mpact of standardizing the cardiac arrest telephone number is nknown. Standardizing cardiac arrest telephone numbers seems logical n order to improve patient safety. Universal knowledge of the

Elevated calprotectin in patients with atrial fibrillation with and without heart failure

Abstract Calprotectin is an inflammatory marker, which has been found elevated in patients suffering from cardiac conditions, e.g. myocardial infarction, unstable angina and chronic heart failure. Inflammation has further been linked to atrial fibrillation (AF). However, the association between calprotectin and AF is unknown. We aimed to compare calprotectin levels in patients suffering from AF with healthy adults. In addition, AF patients with and without heart failure were compared. Calprotectin was measured in patients undergoing elective direct current cardioversion for AF. Calprotectin was determined before, 4 hours and 3 months after cardioversion. Healthy blood donors were used to verify the reference interval for calprotectin. In total, 104 prospectively enrolled patients were included. The median serum calprotectin level for AF patients was 1.6 μg/mL before cardioversion. Calprotectin levels increased significantly 4 h (1.9 μg/mL) and 3 months (2.2 μg/mL) after cardioversion. Blood donors’ median serum calprotectin (1.3 μg/mL) was significantly lower than AF patients. AF patients with heart failure had significantly higher calprotectin at baseline compared with AF patients without a history of heart failure (2.0 μg/mL vs. 1.5 μg/mL). The difference was not significant at 4 h (2.0 μg/mL vs. 1.7 μg/mL) or 3 months (2.5 μg/mL vs. 2.2 μg/mL). In conclusion, the calprotectin levels in patients with AF were significantly higher than healthy blood donors and were further increased after cardioversion. AF patients with heart failure had significantly higher levels of calprotectin than AF patients without heart failure.

Appropriate Use of High-Sensitivity Cardiac Troponin Levels in Patients With Suspected Acute Myocardial Infarction

Appropriate Use of High-Sensitivity Cardiac Troponin Levels in Patients With Suspected Acute Myocardial Infarction To the Editor We have with great interest read the study by Carlton et al1 on rapid rule-out of acute myocardial infarction (AMI) using high-sensitivity cardiac troponin I (hs-cTnI) level at presentation to the emergency department. This study included a pooled population of 3155 patients with symptoms suggestive of cardiac ischemia but with an electrocardiogram without evidence of ischemia. The study contributes important new knowledge on ruling out AMI. In total, 594 patients (18.8%) were ruled out for AMI at presentation to the emergency department using the limit of detection at 1.2 ng/L as a cutoff. Rule out was performed with a negative predictive value of 99.5%, allowing early discharge. The study used the hs-cTnI analysis (Architect Stat; Abbott Diagnostics), and the authors reported an impressive coefficient of variation of 10% at 4.7 ng/L. However, the assay performance in the study by Carlton et al1 raises a pivotal question: is assay performance in studies comparable with assay performance in daily clinical practice? Batch analysis is frequently used in clinical studies.2-4 In the study by Carlton et al,1 blood samples were frozen at −70°C and analyzed in a batch. Neumann et al5 validated the 1-hour algorithm for the rule-out of AMI but did not report whether batch analysis was used. Data in the Advantageous Predictors of Acute Coronary Syndromes Evaluation trial2 was also based on batch analysis. The performance of the hs-cTnI assay is comparable in the studies by Neumann et al5 and Carlton et al.1 Analyzing blood samples in 1 or a few batches will decrease the intra-assay variability by reducing the influence of ex vivo factors, eg, lot-to-lot variability and recalibration. In clinical settings, blood samples are analyzed sequentially. The analysis of hs-cTnI used in clinical studies may therefore outperform the clinical reality. The findings of the study by Carlton et al1 should therefore be interpreted with caution. We suggest that future studies should investigate the use of hs-cTnI to rule out AMI in a real-life clinical setting with sequential hs-cTnI measurements. Moreover, each hospital should identify a specific cutoff for the assay used in the laboratory before using low hs-cTnI levels at presentation to the emergency department to rule out AMI in clinical practice.

Hospital implementation of resuscitation guidelines and review of CPR training programmes: a nationwide study.

This study aimed to investigate cardiopulmonary resuscitation (CPR) guideline implementation and CPR training in hospitals. This nationwide study included mandatory resuscitation protocols from each Danish hospital. Protocols were systematically reviewed for adherence to the European Resuscitation Council (ERC) 2010 guidelines and CPR training in each hospital. Data were included from 45 of 47 hospitals. Adherence to the ERC basic life support (BLS) algorithm was 49%, whereas 63 and 58% of hospitals adhered to the recommended chest compression depth and rate. Adherence to the ERC advanced life support (ALS) algorithm was 81%. Hospital BLS course duration was [median (interquartile range)] 2.3 (1.5–2.5) h, whereas ALS course duration was 4.0 (2.5–8.0) h. Implementation of ERC 2010 guidelines on BLS is limited in Danish hospitals 2 years after guideline publication, whereas the majority of hospitals adhere to the ALS algorithm. CPR training differs among hospitals.

Clinical experience and skills of physicians in hospital cardiac arrest teams in Denmark: a nationwide study

Background The quality of in-hospital resuscitation is poor and may be affected by the clinical experience and cardiopulmonary resuscitation (CPR) training. This study aimed to investigate the clinical experience, self-perceived skills, CPR training and knowledge of the guidelines on when to abandon resuscitation among physicians of cardiac arrest teams. Methods We performed a nationwide cross-sectional study in Denmark. Telephone interviews were conducted with physicians in the cardiac arrest teams in public somatic hospitals using a structured questionnaire. Results In total, 93 physicians (53% male) from 45 hospitals participated in the study. Median age was 34 (interquartile range: 30–39) years. Respondents were medical students working as locum physicians (5%), physicians in training (79%) and consultants (16%), and the median postgraduate clinical experience was 48 (19–87) months. Most respondents (92%) felt confident in treating a cardiac arrest, while fewer respondents felt confident in performing intubation (41%) and focused cardiac ultrasound (39%) during cardiac arrest. Median time since last CPR training was 4 (2–10) months, and 48% had attended a European Resuscitation Council (ERC) Advanced Life Support course. The majority (84%) felt confident in terminating resuscitation; however, only 9% were able to state the ERC guidelines on when to abandon resuscitation. Conclusion Physicians of Danish cardiac arrest teams are often inexperienced and do not feel competent performing important clinical skills during resuscitation. Less than half have attended an ERC Advanced Life Support course, and only very few physicians know the ERC guidelines on when to abandon resuscitation.

Automated external defibrillation training on the left or the right side – a randomized simulation study

Background Correct placement of the left automated external defibrillator (AED) electrode is rarely achieved. AED electrode placement is predominantly illustrated and trained with the rescuer sitting on the right side of the patient. Placement of the AED electrodes from the left side of the patient may result in a better overview of and access to the left lateral side of the thorax. This study aimed to investigate if training in automated external defibrillation on the left side compared to the right side of a manikin improves left AED electrode placement. Methods Laypeople attending basic life support training were randomized to learn automated external defibrillation from the left or right side of a manikin. After course completion, participants used an AED and placed AED electrodes in a simulated cardiac arrest scenario. Results In total, 40 laypersons were randomized to AED training on the left (n=19 [missing data =1], 63% female, mean age: 47.3 years) and right (n=20, 75% female, mean age: 48.7 years) sides of a manikin. There was no difference in left AED electrode placement when trained on the left or right side: the mean (SD) distances to the recommended left AED electrode position were 5.9 (2.1) cm vs 6.9 (2.2) cm (p=0.15) and to the recommended right AED electrode position were 2.6 (1.5) cm vs 1.8 (0.8) cm (p=0.06), respectively. Conclusion Training in automated external defibrillation on the left side of a manikin does not improve left AED electrode placement compared to training on the right side.

BIPHASIC TRUNCATED EXPONENTIAL WAVEFORM IS SUPERIOR COMPARED TO PULSED BIPHASIC WAVEFORM IN CARDIOVERTING ATRIAL FIBRILLATION AND ATRIAL FLUTTER: A RANDOMIZED CONTROLLED TRIAL

Several different biphasic waveforms are currently in clinical use, but few studies have compared their efficiency. The aim of this study was to compare the efficiency of a biphasic truncated exponential (BTE) waveform with a pulsed biphasic waveform (PBW) in patients undergoing elective