Thea Palsgaard Møller

Efficacy of simulation‐based trauma team training of non‐technical skills. A systematic review

Trauma resuscitation is a complex situation, and most organisations have multi‐professional trauma teams. Non‐technical skills are challenged during trauma resuscitation, and they play an important role in the prevention of critical incidents. Simulation‐based training of these is recommended. Our research question was: Does simulation‐based trauma team training of non‐technical skills have effect on reaction, learning, behaviour or patient outcome?

The Effects of Public Access Defibrillation on Survival After Out-of-Hospital Cardiac Arrest: A Systematic Review of Observational Studies

Background: Despite recent advances, the average survival after out-of-hospital cardiac arrest (OHCA) remains <10%. Early defibrillation by an automated external defibrillator is the most important intervention for patients with OHCA, showing survival proportions >50%. Accordingly, placement of automated external defibrillators in the community as part of a public access defibrillation program (PAD) is recommended by international guidelines. However, different strategies have been proposed on how exactly to increase and make use of publicly available automated external defibrillators. This systematic review aimed to evaluate the effect of PAD and the different PAD strategies on survival after OHCA. Methods: PubMed, Embase, and the Cochrane Library were systematically searched on August 31, 2015 for observational studies reporting survival to hospital discharge in OHCA patients where an automated external defibrillator had been used by nonemergency medical services. PAD was divided into 3 groups according to who applied the defibrillator: nondispatched lay first responders, professional first responders (firefighters/police) dispatched by the Emergency Medical Dispatch Center (EMDC), or lay first responders dispatched by the EMDC. Results: A total of 41 studies were included; 18 reported PAD by nondispatched lay first responders, 20 reported PAD by EMDC-dispatched professional first responders (firefighters/police), and 3 reported both. We identified no qualified studies reporting survival after PAD by EMDC-dispatched lay first responders. The overall survival to hospital discharge after OHCA treated with PAD showed a median survival of 40.0% (range, 9.1–83.3). Defibrillation by nondispatched lay first responders was associated with the highest survival with a median survival of 53.0% (range, 26.0–72.0), whereas defibrillation by EMDC-dispatched professional first responders (firefighters/police) was associated with a median survival of 28.6% (range, 9.0–76.0). A meta-analysis of the different survival outcomes could not be performed because of the large heterogeneity of the included studies. Conclusions: This systematic review showed a median overall survival of 40% for patients with OHCA treated by PAD. Defibrillation by nondispatched lay first responders was found to correlate with the highest impact on survival in comparison with EMDC-dispatched professional first responders. PAD by EMDC-dispatched lay first responders could be a promising strategy, but evidence is lacking.

Barriers to recognition of out-of-hospital cardiac arrest during emergency medical calls: a qualitative inductive thematic analysis.

BackgroundThe chance of surviving out-of-hospital cardiac arrest (OHCA) depends on early and correct recognition of cardiac arrest by the emergency medical dispatcher during the emergency call. When cardiac arrest is identified, telephone guided cardiopulmonary resuscitation (CPR) and referral to an automated external defibrillator should be initiated. Previous studies have investigated barriers to recognition of OHCA, and found the caller’s description of sign of life, the type of caller, caller’s emotional state, an inadequate dialogue during the emergency call, and patient’s agonal breathing as influential factors. Though many of these factors are included in the algorithms used by medical dispatchers, many OHCA still remain not recognised. Qualitative studies investigating the communication between the caller and dispatcher are very scarce. There is a lack of knowledge about what influences the dispatchers’ recognition of OHCA, focusing on the communication during the emergency call.The purpose of this study is to identify factors affecting medical dispatchers’ recognition of OHCA during emergency calls in a qualitative analysis of calls.MethodsAn investigator triangulated inductive thematic analysis of recordings of out-of-hospital cardiac arrest emergency calls from December 2012. Participants were the callers (bystanders) and the emergency medical dispatchers. Data were analysed using a hermeneutic approach.ResultsBased on the concept of data saturation, 13 recordings of not recognised cardiac arrest and 8 recordings of recognised cardiac arrests were analysed. Three main themes, six subthemes and an embedded theme emerged from the analysis: caller’s physical distance (caller near patient, caller not near patient), caller’s emotional distance (keeping calm, losing control), caller is a healthcare professional (responsibility is handed over to the caller, caller assumes responsibility), and the embedded theme: caller assesses the patient.ConclusionThe physical and emotional proximity of the caller (bystander) as well as the caller’s professional background affect the dispatcher’s chances of correct recognition and handling of cardiac arrest. The dispatcher should acknowledge the triple roles of conducting patient assessment, instructing the caller, and reassuring the emotionally affected caller.

Challenges in out-of-hospital cardiac arrest – A study combining closed-circuit television (CCTV) and medical emergency calls

UNLABELLED The aim of this study was to explore challenges in recognition and initial treatment of out-of-hospital cardiac arrest (OHCA) by using closed-circuit television (CCTV) recordings combined with audio recordings from emergency medical calls. METHOD All OHCA captured by CCTV in the Capital Region of Denmark, 15 June 2013-14 June 2014, were included. Using a qualitative approach based on thematic analysis, we focused on the interval from the victims collapse to the arrival of the ambulance. RESULTS Based on the 21 CCTV recordings collected, the main challenges in OHCA seemed to be situation awareness, communication and attitude/approach. Situation awareness among bystanders and the emergency medical dispatchers (dispatcher) differed. CCTV showed that bystanders other than the caller, were often physically closer to the victim and initiated cardiopulmonary resuscitation (CPR). Hence, information from the dispatcher had to pass through the caller to the other bystanders. Many bystanders passed by or left, leaving the resuscitation to only a few. In addition, we observed that the callers did not delegate tasks that could have been performed more effectively by other bystanders, for example, receiving the ambulance or retrieving an Automated External Defibrillator (AED). CONCLUSION CCTV combined with audio recordings from emergency calls can provide unique insights into the challenges of recognition and initial treatment of OHCA and can improve understanding of the situation. The main barriers to effective intervention were situation awareness, communication and attitude/approach. Potentially, some of these challenges could be minimized if the dispatcher was able to see the victim and the bystanders at the scene. A team approach, with the dispatcher responsible for the role as team leader of a remote resuscitation team of a caller and bystanders, may potentially improve treatment of OHCA.

Recognition of out-of-hospital cardiac arrest during emergency calls — a systematic review of observational studies

BackgroundThe medical dispatcher plays an essential role as part of the first link in the Chain of Survival, by recognising the out-of-hospital cardiac arrest (OHCA) during the emergency call, dispatching the appropriate first responder or emergency medical services response, performing dispatcher assisted cardiopulmonary resuscitation, and referring to the nearest automated external defibrillator. The objective of this systematic review was to evaluate and compare studies reporting recognition of OHCA patients during emergency calls.MethodsThis systematic review was reported in compliance with the PRISMA guidelines. We systematically searched MEDLINE, Embase and the Cochrane Library on 4 November 2015. Observational studies, reporting the proportion of clinically confirmed OHCAs that was recognised during the emergency call, were included. Two authors independently screened abstracts and full-text articles for inclusion. Data were extracted and the risk of bias within studies was assessed using the QUADAS-2 tool for quality assessment of diagnostic accuracy studies.ResultsA total of 3,180 abstracts were screened for eligibility and 53 publications were assessed in full-text. We identified 16 studies including 6,955 patients that fulfilled the criteria for inclusion in the systematic review. The studies reported recognition of OHCA with a median sensitivity of 73.9% (range: 14.1–96.9%). The selection of study population and the definition of “recognised OHCA” (threshold for positive test) varied greatly between the studies, resulting in high risk of bias. Heterogeneity in the studies precluded meta-analysis.ConclusionAmong the 16 included studies, we found a median sensitivity for OHCA recognition of 73.9% (range: 14.1–96.9%). However, great heterogeneity between study populations and in the definition of “recognised OHCA”, lead to insufficient comparability of results. Uniform and transparent reporting is required to ensure comparability and development towards best practice.

Recognition of out-of-hospital cardiac arrest by medical dispatchers in emergency medical dispatch centres in two countries

INTRODUCTION Survival after out-of-hospital cardiac arrest (OHCA) remains low. Early recognition by emergency medical dispatchers is essential for an effective chain of actions, leading to early cardiopulmonary resuscitation, use of an automated external defibrillator and rapid dispatching of the emergency medical services. AIM To analyse and compare the accuracy of OHCA recognition by medical dispatchers in two countries. METHOD An observational register-based study collecting data from national cardiac arrest registers in Denmark and Sweden during a six-month period in 2013. Data were analysed in two steps; registry data were merged with electronically registered emergency call data from the emergency medical dispatch centres in the two regions. Cases with missing or non-OHCA dispatch codes were analysed further by auditing emergency call recordings using a uniform data collection template. RESULTS The sensitivity for recognition of OHCA was 40.9% (95% CI: 37.1-44.7%) in the Capital Region of Denmark and 78.4% (95% CI: 73.2-83.0%) in the Skåne Region in Sweden (p<0.001). With additional data from the emergency call recordings, the sensitivity was 80.7% (95% CI: 77.7-84.3%) and 86.0% (95% CI: 81.3-89.8%) for the two regions (p=0.06). The majority of the non-recognised OHCA were dispatched with the highest priority. CONCLUSION The accuracy of OHCA recognition was high and comparable. We identified large differences in data registration practices despite the use of similar dispatch tools. This raises a discussion of definitions and transparency in general in scientific reporting of OHCA recognition, which is essential if used as quality indicator in emergency medical services.

The difficult medical emergency call: A register-based study of predictors and outcomes

BackgroundPre-hospital emergency care requires proper categorization of emergency calls and assessment of emergency priority levels by the medical dispatchers. We investigated predictors for emergency call categorization as “unclear problem” in contrast to “symptom-specific” categories and the effect of categorization on mortality.MethodsRegister-based study in a 2-year period based on emergency call data from the emergency medical dispatch center in Copenhagen combined with nationwide register data. Logistic regression analysis (N = 78,040 individuals) was used for identification of predictors of emergency call categorization as “unclear problem”. Poisson regression analysis (N = 97,293 calls) was used for examining the effect of categorization as “unclear problem” on mortality.Results“Unclear problem” was the registered category in 18% of calls. Significant predictors for “unclear problem” categorization were: age (odds ratio (OR) 1.34 for age group 76+ versus 18–30 years), ethnicity (OR 1.27 for non-Danish vs. Danish), day of week (OR 0.92 for weekend vs. weekday), and time of day (OR 0.79 for night vs. day). Emergency call categorization had no effect on mortality for emergency priority level A calls, incidence rate ratio (IRR) 0.99 (95% confidence interval (CI) 0.90–1.09). For emergency priority level B calls, an association was observed, IRR 1.26 (95% CI 1.18–1.36).DiscussionsThe results shed light on the complexity of emergency call handling, but also implicate a need for further improvement. Educational interventions at the dispatch centers may improve the call handling, but also the underlying supportive tools are modifiable. The higher mortality rate for patients with emergency priority level B calls with “unclear problem categorization” could imply lowering the threshold for dispatching a high level ambulance response when the call is considered unclear. On the other hand a “benefit of the doubt” approach could hinder the adequate response to other patients in need for an ambulance as there is an increasing demand and limited resources for ambulance services.ConclusionsAge, ethnicity, day of week and time of day were significant predictors of emergency call categorization as “unclear problem”. “Unclear problem” categorization was not associated with mortality for emergency priority level A calls, but a higher mortality was observed for emergency priority level B calls.

Effect of bystander CPR initiation prior to the emergency call on ROSC and 30 day survival—An evaluation of 548 emergency calls

BACKGROUND This study aimed at evaluating if time for initiation of bystander cardiopulmonary resuscitation (CPR) - prior to the emergency call (CPRprior) versus during the emergency call following dispatcher-assisted CPR (CPRduring) - was associated with return of spontaneous circulation (ROSC) and 30-day survival. The secondary aim was to identify predictors of CPRprior. METHODS This observational study evaluated out-of-hospital cardiac arrests (OHCA) occurring in the Capital Region of Denmark from 01.01.2013 to 31.12.2013. OHCAs were linked to emergency medical dispatch centre records and corresponding emergency calls were evaluated. Multivariable logistic regression analyses were applied to evaluate the association between time for initiation of bystander CPR, ROSC, and 30-day survival. Univariable logistic regression analyses were applied to identify predictors of CPRprior. RESULTS The study included 548 emergency calls for OHCA patients receiving bystander CPR, 34.9% (n=191) in the CPRprior group and 65.1% (n=357) in the CPRduring group. Multivariable analyses showed no difference in ROSC (OR=0.88, 95% CI: 0.56-1.38) or 30-day survival (OR=1.14, 95% CI: 0.68-1.92) between CPRprior and CPRduring. Predictors positively associated with CPRprior included witnessed OHCA and healthcare professional bystanders. Predictors negatively associated with CPRprior included residential location, solitary bystanders, and bystanders related to the patient. CONCLUSIONS The majority of bystander CPR (65%) was initiated during the emergency call, following dispatcher-assisted CPR instructions. Whether bystander CPR was initiated prior to emergency call versus during the emergency call following dispatcher-assisted CPR was not associated with ROSC or 30-day survival. Dispatcher-assisted CPR was especially beneficial for the initiation of bystander CPR in residential areas.

Danish first aid books compliance with the new evidence-based non-resuscitative first aid guidelines

BackgroundThe European Resuscitation Council (ERC) released new guidelines on resuscitation in 2015. For the first time, the guidelines included a separate chapter on first aid for laypersons. We analysed the current major Danish national first aid books to identify potential inconsistencies between the current books and the new evidence-based first aid guidelines.MethodsWe identified first aid books from all the first aid courses offered by major Danish suppliers. Based on the new ERC first aid guidelines, we developed a checklist of 26 items within 16 different categories to assess the content; this checklist was adapted following the principle of mutually exclusive and collectively exhaustive questioning. To assess the agreement between four raters, Fleiss’ kappa test was used. Items that did not reach an acceptable kappa score were excluded.ResultsWe evaluated 10 first aid books used for first aid courses and published between 2009 and 2015. The content of the books complied with the new in 38% of the answers.In 12 of the 26 items, there was less than 50% consistency. These items include proximal pressure points and elevation of extremities for the control of bleeding, use of cervical collars, treatment for an open chest wound, burn dressing, dental avulsion, passive leg raising, administration of bronchodilators, adrenaline, and aspirin.ConclusionsDanish course material showed significant inconsistencies with the new evidence-based first aid guidelines. The new knowledge from the evidence-based guidelines should be incorporated into revised and updated first aid course material.

Different defibrillation strategies in survivors after out-of-hospital cardiac arrest

Background In the last decade, there has been a rapid increase in the dissemination of automated external defibrillators (AEDs) for prehospital defibrillation of out-of-hospital cardiac arrest patients. The aim of this study was to study the association between different defibrillation strategies on survival rates over time in Copenhagen, Stockholm, Western Sweden and Amsterdam, and the hypothesis was that non-EMS defibrillation increased over time and was associated with increased survival. Methods We performed a retrospective analysis of four prospectively collected cohorts of out-of-hospital cardiac arrest patients between 2008 and 2013. Emergency medical service (EMS)-witnessed arrests were excluded. Results A total of 22 453 out-of-hospital cardiac arrest patients with known survival status were identified, of whom 2957 (13%) survived at least 30 days postresuscitation. Of all survivors with a known defibrillation status, 2289 (81%) were defibrillated, 1349 (59%) were defibrillated by EMS, 454 (20%) were defibrillated by a first responder AED and 429 (19%) were defibrillated by an onsite AED and 57 (2%) were unknown. The percentage of survivors defibrillated by first responder AEDs (from 13% in 2008 to 26% in 2013, p<0.001 for trend) and onsite AEDs (from 14% in 2008 to 30% in 2013, p<0.001 for trend) increased. The increased use of these non-EMS AEDs was associated with the increase in survival rate of patients with a shockable initial rhythm. Conclusion Survivors of out-of-hospital cardiac arrest are increasingly defibrillated by non-EMS AEDs. This increase is primarily due to a large increase in the use of onsite AEDs as well as an increase in first-responder defibrillation over time. Non-EMS defibrillation accounted for at least part of the increase in survival rate of patients with a shockable initial rhythm.