Scott Compton

The Public Access Defibrillation (PAD) trial: study design and rationale.

The PAD Trial is a prospective, multicenter, randomized clinical study testing whether volunteer, non-medical responders can improve survival from out-of-hospital cardiac arrest (OOH-CA) by using automated external defibrillators (AEDs). These lay volunteers, who have no traditional responsibility to respond to a medical emergency as part of their primary job description, will form part of a comprehensive, integrated community approach to the treatment of OOH-CA. The study is being conducted at 24 field centers in the United States and Canada. Approximately 1000 community units (e.g. apartment or office buildings, gated communities, sports facilities, senior centers, shopping malls, etc.) were randomized to treatment by trained laypersons who will provide either cardiopulmonary resuscitation (CPR) alone or CPR plus use of an AED, while awaiting arrival of the communitys emergency medical services responders. The primary endpoint is the number of OOH-CA victims who survive to hospital discharge. Secondary endpoints include neurological status, health-related quality of life (HRQL), cost, and cost-effectiveness. Data collection will last approximately 15 months and is expected to be completed in September 2003.

Cardiac arrest in private locations: different strategies are needed to improve outcome☆

BACKGROUND A tremendous amount of public resources are focused on improving cardiac arrest (OHCA) survival in public places, yet most OHCAs occur in private residences. METHODS AND RESULTS A prospective, observational study of patients transported to seven urban and suburban hospitals and the individuals who called 911 at the time of a cardiac arrest (bystander) was performed. Bystanders (N=543) were interviewed via telephone beginning 2 weeks after the incident to obtain data regarding patient and bystander demographics, including cardiopulmonary resuscitation (CPR) training. Of all arrests 80.2% were in homes. Patients who arrested in public places were significantly younger (63.2 vs. 67.2, P<0.02), more often had an initial rhythm of VF (63.0 vs. 37.7%, P<0.001), were seen or heard to have collapsed by a bystander (74.8 vs. 48.1%, P<0.001), received bystander CPR (60.2 vs. 28.6%, P<0.001), and survived to DC (17.5 vs. 5.5%, P<0.001). Patients who arrested at home were older and had an older bystander (55.4 vs. 41.3, P<0.001). The bystander was less likely to be CPR trained (65.0 vs. 47.4%, P<0.001), less likely to be trained within the last 5 years (49.2 vs. 17.9, P<0.001), and less likely to perform CPR if trained (64.2 vs. 30.0%, P<0.001). Collapse to shock intervals for public versus home VF patients were not different. CONCLUSIONS Many important characteristics of cardiac arrest patients and the bystander differ in public versus private locations. Fundamentally different strategies are needed to improve survival from these events.

The presence of a family witness impacts physician performance during simulated medical codes.

Objective:To determine whether the presence and behavior of a family witness to cardiopulmonary resuscitation (CPR) impacts critical actions performed by physicians. Design:This was a randomized comparison study of physicians’ performance during a simulated cardiac arrest with three different family witness states. Setting:This study was conducted at the Wayne State University Eugene Applebaum College of Pharmacy and Health Science’s Center for Healthcare Simulation. Subjects:Second-year and third-year emergency medicine (EM) residents from the Wayne State University Department of Emergency Medicine–affiliated residency programs and Michigan State University–affiliated EM residency programs. Intervention:Thirty teams comprised of one second-year and one third-year EM resident were randomly assigned to one of the three groups: 1) no family witness; 2) a nonobstructive “quiet” family witness; and 3) a family witness displaying an overt grief reaction. Measurements and Main Results:Each pair was assessed for time to critical actions (e.g., minutes to CPR and drug administration) and for resuscitation-based performance outcomes (e.g., number of shocks) during a simulated cardiac arrest. The time to critical events was similar across groups with respect to initiating CPR, attempting to intubate the patient, and pronouncing the death of the patient. However, the time to deliver the first defibrillation shock was longer for the overt reaction witness group (2.57 minutes) as compared with the quiet (1.77 minutes) and no family witness (1.67 minutes) groups. Additionally, fewer total shocks were delivered in the overt reaction witness groups (4.0 minutes) vs. the quiet (6.5 minutes) and no family witness groups (6.0 minutes). Conclusion:The presence of a family witness may have a significant impact on physicians’ ability to perform critical actions during simulated medical resuscitations. Further study is necessary to see if this effect crosses over into real clinical practice and if training ameliorates this effect.

Tolerance for Uncertainty, Burnout, and Satisfaction With the Career of Emergency Medicine

STUDY OBJECTIVE Questions about burnout, career satisfaction, and longevity of emergency physicians have been raised but no studies have examined tolerance for uncertainty as a risk factor for burnout. Primary objectives of this study are to assess the role of uncertainty tolerance in predicting career burnout and to estimate the proportion of emergency physicians who exhibit high levels of career burnout. METHODS A mail survey incorporating validated measures of career satisfaction, tolerance for uncertainty, and burnout was sent to a random sample of members of the American College of Emergency Physicians. Best- and worst-case scenarios of point estimates are provided to assess for the effect of nonresponse bias, and multivariable logistic regression was used to predict evidence of career burnout. RESULTS One hundred ninety-three surveys were returned (response rate 43.1%). A high level of career burnout was exhibited in 62 (32.1%; best-worst case 13.8% to 64.1%) respondents. No demographic variables were associated with burnout status. The final model identified that high anxiety caused by concern for bad outcomes (odds ratio=6.35) was the strongest predictor of career burnout, controlling for all other variables. CONCLUSION A large percentage of emergency physicians in this study, 32.1%, exhibited emotional exhaustion, which is the core symptom of burnout. Emotional exhaustion was not related to age or type of practice and was not mitigated by training in emergency medicine. Physicians studied did not feel anxiety because of general uncertainty, difficulty in disclosing uncertainty to patients, or admitting errors to other physicians. High anxiety caused by concern for bad outcomes was the strongest predictor of burnout. Despite exhibiting emotional exhaustion, the majority of respondents are satisfied with the career of emergency medicine.

A randomized controlled trial of chest compression only CPR for older adults-a pilot study.

UNLABELLED Older people are trained infrequently in cardiopulmonary resuscitation (CPR), yet are more likely to witness a cardiac arrest. Older people who are CPR trained perform CPR when witnessing a cardiac arrest. OBJECTIVE To assess whether elderly adults (>55 years) who receive chest-compression only cardiopulmonary resuscitation (CC-CPR) training display equivalent skill retention rates compared with those who receive traditional CPR instruction. We also identified factors associated with 3 months skill retention at 3 months in both groups. METHODS Older adults in a suburban hospital Older Adult Services program were invited to participate in an experimental CPR course. The 2 h course was modelled after the AHA Friends and Family course, and used one of two standardized video scenarios. Seventy four subjects were randomized to CC-CPR (n=36) or traditional CPR (n=38) training. Participation consisted of initial training, followed by a 3 months return videotaped assessment. Three months skill competence was assessed either by consensus between two video evaluators, or the on-site evaluator. Chi square and Kappa tests were used for analysis, and unadjusted odds ratios and 95% confidence intervals are reported. RESULTS Skill retention assessments were completed on 29 (81%) CC-CPR and 26 (68%) CPR trainees. Subjects were elderly (71.5+/-6.69 years), and had a high rate of previous CPR training (58.0%). Groups were similar in demographic characteristics. After training, participants exhibited high rates of perceived competence (86.4%), although the overall 3 months skill retention was low (43.6%). CC-CPR training resulted in equivalent skill retention rates as compared with traditional CPR training (51.7 vs. 44.4%; P=0.586). No participant factors were associated with skill retention, including age, previous CPR training, education level, medical history, or perceived physical ability to perform. CONCLUSION We identified low rates of CPR skill retention in this elderly population. CC-CPR instruction was associated with equivalent skill retention rates compared with traditional CPR instruction. No demographic factors were associated with successful skill retention.

Prehospital on-site triaging.

Objective. To estimate the proportion of patients transported by emergency medical services (EMS) who do not need immediate emergency medical care. Secondary objectives were: 1) to evaluate the ability of paramedics to determine which patients need immediate ambulance transport, and 2) to evaluate on-scene patient characteristics that may aid in developing an EMS transport protocol. Methods. A prospective cross-sectional study design was utilized to estimate the percentage of low-risk patients eligible for non-ambulance transport among 277 patients transported to an emergency department via ambulance. The EMS personnel prospectively rated each patient as to need for immediate ambulance transport. Physician raters, using predefined criteria, determined eligibility for non-ambulance transport. Results. There were 116 patients (59.2%, 95% CI = 53.4%–65.0%) who were not in need of immediate emergency medical care. Comparison of the EMS personnels rating with the criterion-standard need for emergency treatment transport yielded a sensitivity of 22.1% (95% CI = 13.9%–30.2%) and a specificity of 80.5% (95% CI = 72.5%–88.3%). Chief complaints of abdominal pain (OR = 2.94, 95% CI = 1.31–6.60) and administration of oxygen (OR = 2.13, 95% CI = 1.06–4.29) were independently associated with the need for ambulance transport, while young age (OR = 0.28, 95% CI = 0.09–0.90) was negatively associated. Conclusions. The majority of patients triaged as low-risk were not in need of immediate ambulance transport for emergency medical care. However, EMS personnel, unaided by triage protocols or specific training, could not reliably identify those patients in need of emergency medical treatment, and few factors were identified to assist that decision.

Epidemiology of Pediatric Transports and Non-Transports in an Urban Emergency Medical Services System

Objective. This study was done to describe an urban, Emergency Medical Service (EMS) systems experiences with pediatric patients andthe rate andcharacteristics of non-transports in this setting. Methods. A retrospective analysis of all pediatric patients responded to by the Detroit Fire Department Division of EMS between January 1, 2002 andAugust 30, 2002 was done. Results. There were 5,976 pediatric EMS cases. Children 10 years of age or older accounted for 49.4% of transports, 53.8% of all patients had medical illness, and38.8% of the patients belonged to the non-urgent category. A large percentage of patients were not transported (27.2%), most commonly secondary to parent/caregiver/patient refusals. The median number of minutes on-scene for refusals was longer than for transports (23.5 vs. 17.3, respectively)[difference = 6.2 minutes (95% CI: 5.6–6.9)]. The odds ratios (OR) for refusal was highest for assaults (2.09; 95% CI: 1.66–2.63), difficulty in breathing (1.38; 95% CI: 1.14–1.68), andmotor vehicle accidents (1.19; 95% CI: 1.04–1.37). Conclusions. In this system, the majority of pediatric patients are not severely ill, anda large number are not transported. Non-transports are more likely to be young adolescents, have been involved in assaults, andhave a longer on-scene time.

Descriptive analysis of the in-hospital course of patients who initially survive out-of-hospital cardiac arrest but die in-hospital.

OBJECTIVE To describe the postresuscitative hospital course of emergency department patients who initially survive nontraumatic out-of-hospital cardiac arrests (OOHCA) but die in the hospital. METHODS A 12-month case series of all nontraumatic OOHCA patients at two large urban Midwestern teaching hospitals who survived to hospital admission but died before discharge. Medical records from identified patients were reviewed for demographics, resuscitation sequelae, do-not-attempt-resuscitation (DNAR) code status, pain declarations, and withdrawal of life support. Descriptive statistics are reported. RESULTS Between August 31, 2005 and July 31, 2006, there were 468 nontraumatic OOHCA patients treated at the study hospitals. Forty-one (8.8%) patients initially survived and were admitted to the hospital, of whom 32 (78.0%) expired before hospital discharge. Pain declarations were noted in 8 (25.0%) patients, of whom 4 had more than one assessment. Median postresuscitation survival time was 1.5 days (range, 9.3 hours to 18.6 days). Overall, 19 (59.4%) patients died after withdrawal of life support, 8 (25.0%) while actively on life support, and 5 (15.6%) died with subsequent cardiopulmonary resuscitation (CPR). Possible complications of CPR included pneumothorax in 2 (6.3%) and intracranial hemorrhage in 1 (3.1%). CONCLUSIONS In this urban setting, approximately three of four OOHCA patients who are initially resuscitated do not survive to hospital discharge. This short in-hospital course post-CPR is often marked by pain and ends with the withdrawal of life support. This information may be an important component of advance planning discussions and may assist patients as they weigh the pros and cons associated with resuscitation preferences.

Early identification of dying trajectories in emergency department patients: potential impact on hospital care.

Emergency departments (EDs) provide care for many patients with an advanced, life-limiting illness. The ED clinical focus is on resuscitation and stabilization and suits the needs of the acutely ill and injured. However, this approach may not be concordant to patient goals-of-care in the seriously ill with chronic, severe end-stage, life-limiting disease. Initial ED management sets the trajectory for inpatient disposition/care, prompting palliative care (PC) leaders to recommend early patient-centered ED goal setting. Challenges include a lack of buy-in from ED clinicians and a hectic ED environment with competing demands. However, a onesize-fits-all approach to ED care is not optimal in the terminally ill. A simple approach to prognostication may serve as a trigger for goals-of-care considerations (or palliative team consults). To our knowledge, no study addresses early ED prognostication and impact on subsequent care provision and palliative outcomes. Lunney and colleagues define functional trajectories based on disease diagnosis/ progression/functional decline to serve as a prognostic guideline so patients/clinician can prepare for subsequent care and death. In this study we retrospectively classify patients that presented to the ED and subsequently died following hospital admission into such dying trajectories. The purpose was to compare subsequent inpatient care provision and related outcomes between those trajectory groups.

Hospital costs and revenue are similar for resuscitated out-of-hospital cardiac arrest and ST-segment acute myocardial infarction patients.

OBJECTIVES Care provided to patients who survive to hospital admission after out-of-hospital cardiac arrest (OOHCA) is sometimes viewed as expensive and a poor use of hospital resources. The objective was to describe financial parameters of care for patients resuscitated from OOHCA. METHODS This was a retrospective review of OOHCA patients admitted to one academic teaching hospital from January 2004 to October 2007. Demographic data, length of stay (LOS), and discharge disposition were obtained for all patients. Financial parameters of patient care including total cost, net revenue, and operating margin were calculated by hospital cost accounting and reported as median and interquartile range (IQR). Groups were dichotomized by survival to discharge for subgroup analysis. To provide a reference group for context, similar financial data were obtained for ST-segment elevation myocardial infarction (STEMI) patients admitted during the same time period, reported with medians and IQRs. RESULTS During the study period, there were 72 admitted OOCHA patients and 404 STEMI patients. OOCHA and STEMI groups were similar for age, sex, and insurance type. Overall, 27 (38.6%) OOHCA patients survived to hospital discharge. Median LOS for OOHCA patients was 4 days (IQR = 1-8 days), with most of those hospitalized for <or=4 days (n = 34, 81.0% dying or discharged to hospice care). Median net revenue (