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Abstract: Objective: Shallow chest compressions and incomplete recoil are common during cardiopulmonary resuscitation (CPR) and negatively affect outcomes. A step stool has the potential to alter these parameters when performing CPR in a bed but the impact has not been quantified. Methods: We conducted a cross-over design, simulated study of in-hospital cardiac arrest. Rescuers performed a total of four 2-min segments of uninterrupted chest compressions, half of which were on a step stool. Compression characteristics were measured using a CPR-sensing defibrillator and subjective impressions were obtained from rescuer surveys. Paired analyses were performed to measure the impact of the step stool, taking into account rescuer characteristics, including height. Results: Fifty subjects, of whom 36% were men, with a median height of 169.8cm (range 148.6–190.5) volunteered to participate. Use of a step stool resulted in an average increase in compression depth of 4mm (p <0.001) and 18% increase in incomplete recoil (p <0.001). However, unlike with incomplete recoil, the effect was more pronounced in rescuers in the lowest height tertile (9±9mm vs 2±6mm for those rescuers taller than 167cm, p =0.006). Conclusions: Using a step stool when performing CPR in a bed results in a trade-off between increased compression depth and increased incomplete recoil. Given the nonlinear relationship between the increase in compression depth and rescuer height, the benefit of a step stool may outweigh the risks of incomplete release for rescuers ≤167cm in height. The benefit is less clear in taller rescuers. [Copyright &y& Elsevier]

Abstract: Background: Pauses in chest compressions during cardiopulmonary resuscitation have been shown to correlate with poor outcomes. In an attempt to minimize these pauses, the American Heart Association recommends charging the defibrillator during chest compressions. While simulation work suggests decreased pause times using this technique, little is known about its use in clinical practice. Methods: We conducted a multi-center, retrospective study of defibrillator charging at three US academic teaching hospitals between April 2006 and April 2009. Data were abstracted from CPR-sensing defibrillator transcripts. Pre-shock pauses and total hands-off time preceding the defibrillation attempts were compared among techniques. Results: A total of 680 charge-cycles from 244 cardiac arrests were analyzed. The defibrillator was charged during ongoing chest compressions in 448 (65.9%) instances with wide variability across the three sites. Charging during compressions correlated with a decrease in median pre-shock pause [2.6s (IQR 1.9–3.8) vs 13.3s (IQR 8.6–19.5); p <0.001] and total hands-off time in the 30s preceding defibrillation [10.3s (IQR 6.4–13.8) vs 14.8s (IQR 11.0–19.6); p <0.001]. The improvement in hands-off time was most pronounced when rescuers charged the defibrillator in anticipation of the pause, prior to any rhythm analysis. There was no difference in inappropriate shocks when charging during chest compressions (20.0% vs 20.1%; p =0.97) and there was only one instance noted of inadvertent shock administration during compressions, which went unnoticed by the compressor. Conclusions: Charging during compressions is underutilized in clinical practice. The technique is associated with decreased hands-off time preceding defibrillation, with minimal risk to patients or rescuers. [Copyright &y& Elsevier]

Abstract: Objective: Hyperventilation is both common and detrimental during cardiopulmonary resuscitation (CPR). Chest-wall impedance algorithms have been developed to detect ventilations during CPR. However, impedance signals are challenged by noise artifact from multiple sources, including chest compressions. Capnography has been proposed as an alternate method to measure ventilations. We sought to assess and compare the adequacy of these two approaches. Methods: Continuous chest-wall impedance and capnography were recorded during consecutive in-hospital cardiac arrests. Algorithms utilizing each of these data sources were compared to a manually determined “gold standard” reference ventilation rate. In addition, a combination algorithm, which utilized the highest of the impedance or capnography values in any given minute, was similarly evaluated. Results: Data were collected from 37 cardiac arrests, yielding 438min of data with continuous chest compressions and concurrent recording of impedance and capnography. The manually calculated mean ventilation rate was 13.3±4.3/min. In comparison, the defibrillator''s impedance-based algorithm yielded an average rate of 11.3±4.4/min (p =0.0001) while the capnography rate was 11.7±3.7/min (p =0.0009). There was no significant difference in sensitivity and positive predictive value between the two methods. The combination algorithm rate was 12.4±3.5/min (p =0.02), which yielded the highest fraction of minutes with respiratory rates within 2/min of the reference. The impedance signal was uninterpretable 19.5% of the time, compared with 9.7% for capnography. However, the signals were only simultaneously non-interpretable 0.8% of the time. Conclusions: Both the impedance and capnography-based algorithms underestimated the ventilation rate. Reliable ventilation rate determination may require a novel combination of multiple algorithms during resuscitation. [Copyright &y& Elsevier]

Abstract: Background: Rescuer fatigue during cardiopulmonary resuscitation (CPR) is a likely contributor to variable CPR quality during clinical resuscitation efforts, yet investigations into fatigue and CPR quality degradation have only been performed in simulated environments, with widely conflicting results. Objective: We sought to characterize CPR quality decay during actual in-hospital cardiac arrest, with regard to both chest compression (CC) rate and depth during the delivery of CCs by individual rescuers over time. Methods: Using CPR recording technology to objectively quantify CCs and provide audiovisual feedback, we prospectively collected CPR performance data from arrest events in two hospitals. We identified continuous CPR “blocks” from individual rescuers, assessing CC rate and depth over time. Results: 135 blocks of continuous CPR were identified from 42 cardiac arrests at the two institutions. Median duration of continuous CPR blocks was 112s (IQR 101–122). CC rate did not change significantly over single rescuer performance, with an initial mean rate of 105±11/min, and a mean rate after 3min of 106±9/min (p =NS). However, CC depth decayed significantly between 90s and 2min, falling from a mean of 48.3±9.6mm to 46.0±9.0mm (p =0.0006) and to 43.7±7.4mm by 3min (p =0.002). Conclusions: During actual in-hospital CPR with audiovisual feedback, CC depth decay became evident after 90s of CPR, but CC rate did not change. These data provide clinical evidence for rescuer fatigue during actual resuscitations and support current guideline recommendations to rotate rescuers during CC delivery. [Copyright &y& Elsevier]

Summary: Background: CPR quality is an important determinant of cardiac arrest outcome. Recent investigations have demonstrated that quality of clinical CPR is variable and often not in compliance with international consensus guidelines. The 2005 update of these guidelines included new recommendations for the measurement of resuscitation and CPR performance and the institution of measures to improve resuscitation care. Common definitions and reporting templates need to be established for the variables of CPR quality. This will allow for meaningful comparisons between treatment groups in clinical trials as well as a common system for quality improvement and documentation of this improvement. Methods/results: In this report, we present the results from an international consensus working group to propose common definitions and criteria for reporting variables of CPR quality, based on the best available data for the importance of various CPR variables. The recommendations are discussed in light of the different purposes outlined above. [Copyright &y& Elsevier]

Summary: Background: Semi-automatic defibrillation requires pauses in chest compressions during ECG analysis and charging, and prolonged pre-shock compression pauses reduce the chance of a return of spontaneous circulation (ROSC). We hypothesised that pauses are shorter for manual defibrillation by trained rescuers, but with an increased number of inappropriate shocks given for a non-VF/VT rhythm. Methods: From a prospective study of CPR quality during in- and out-of-hospital cardiac arrest, the duration of pre-shock, inter-shock, and post-shock pauses were compared with Mann–Whitney U-test during manual and AED mode with the same defibrillator, and proportions of inappropriate shocks were compared with Chi-squared tests. Results: A 635 manual and 530 semi-automatic shocks were studied. Number of shocks per episode was similar for the two groups. All pauses measured in seconds (s) were shorter for manual use (P <0.0001); median (25, 75 percentiles); 15 (11, 21) versus 22 (18, 28) pre-shock, 13 (9, 20) versus 23 (22, 26) inter-shock, and 9 (6, 18) versus 20 (11, 31) post-shock, but 163 (26%) manual shocks were inappropriate compared with 30 (6%) AED shocks, odds ratio (OR) 5.7 (95% CI; 3.8–8.7). A 150 (78%) of the inappropriate shocks were delivered for organised rhythms. The proportion of inappropriate manual shocks was higher for resident physicians in-hospital than paramedics out-of-hospital; 77/228 (34%) versus 86/407 (21%), OR 1.9 (1.3–2.7). Conclusion: Manual defibrillation resulted in shorter pauses in chest compressions, but a higher frequency of inappropriate shocks. A higher formal level of education did not prevent inappropriate shocks. Trial registration http://www.clinicaltrials.gov/ (NCT00138996 and NCT00228293). [Copyright &y& Elsevier]

Summary: Background: Cardiopulmonary resuscitation (CPR) quality during actual cardiac arrest has been found to be deficient in several recent investigations. We hypothesized that real-time feedback during CPR would improve the performance of chest compressions and ventilations during in-hospital cardiac arrest. Methods: An investigational monitor/defibrillator with CPR-sensing and feedback capabilities was used during in-hospital cardiac arrests from December 2004 to December 2005. Chest compression and ventilation characteristics were recorded and quantified for the first 5min of resuscitation and compared to a baseline cohort of arrest episodes without feedback, from December 2002 to April 2004. Results: Data from 55 resuscitation episodes in the baseline pre-intervention group were compared to 101 resuscitations in the feedback intervention group. There was a trend toward improvement in the mean values of CPR variables in the feedback group with a statistically significant narrowing of CPR variable distributions including chest compression rate (104±18 to 100±13min−1; test of means, p =0.16; test of variance, p =0.003) and ventilation rate (20±10 to 18±8min−1; test of means, p =0.12; test of variance, p =0.04). There were no statistically significant differences between the groups in either return of spontaneous circulation or survival to hospital discharge. Conclusions: Real-time CPR-sensing and feedback technology modestly improved the quality of CPR during in-hospital cardiac arrest, and may serve as a useful adjunct for rescuers during resuscitation efforts. However, feedback specifics should be optimized for maximal benefit and additional studies will be required to assess whether gains in CPR quality translate to improvements in survival. [Copyright &y& Elsevier]

Summary: Background: Cardiopulmonary resuscitation (CPR) and electrical defibrillation are the primary treatment options for ventricular fibrillation (VF). While recent studies have shown that providing CPR prior to defibrillation may improve outcomes, the effects of CPR quality remain unclear. Specifically, the clinical effects of compression depth and pauses in chest compression prior to defibrillation (pre-shock pauses) are unknown. Methods: A prospective, multi-center, observational study of adult in-hospital and out-of-hospital cardiac resuscitations was conducted between March 2002 and December 2005. An investigational monitor/defibrillator equipped to measure compression characteristics during CPR was used. Results: Data were analyzed from 60 consecutive resuscitations in which a first shock was administered for VF. The primary outcome was first shock success defined as removal of VF for at least 5s following defibrillation. A logistic regression analysis demonstrated that successful defibrillation was associated with shorter pre-shock pauses (adjusted odds ratio 1.86 for every 5s decrease; 95% confidence interval 1.10–3.15) and higher mean compression depth during the 30s of CPR preceding the pre-shock pause (adjusted odds ratio 1.99 for every 5mm increase; 95% confidence interval 1.08–3.66). Conclusions: The quality of CPR prior to defibrillation directly affects clinical outcomes. Specifically, longer pre-shock pauses and shallow chest compressions are associated with defibrillation failure. Strategies to correct these deficiencies should be developed and consideration should be made to replacing current-generation automated external defibrillators that require long pre-shock pauses for rhythm analysis. [Copyright &y& Elsevier]

Introduction: Maternal mortality has risen in the United States during the 21st century. Factors influencing outcome of maternal cardiac arrest (MCA) remain largely unexplored.Objective: We sought to further elucidate the factors affecting maternal death from in-hospital (IH) MCA.Methods: Our query of the American Heart Association's GWTG®-Resuscitation voluntary registry from 2000-2017 revealed 561 index cases of IH MCA with complete outcome data. Logistic regression was performed using hospital death as the primary outcome and included variables with a p value = 0.1 or less based upon univariate analysis. Age, race, year of arrest, pre-existing conditions, first documented pulseless rhythm and location of arrest were used in the model. Sensitivity analyses and assessment of variable interaction were also performed to test model stability. Institutional review deemed this research exempt from ethical approval.Results: Among 561 cases of MCA, 57.2% (321/561) did not survive to hospital discharge. IH death was not associated with maternal age, race and year of event. In the final model, IH death was significantly associated with pre-arrest hypotension/hypoperfusion (OR = 1.80 (95% CI, 1.16-2.79); p = 0.009). The occurrence of MCA outside of the delivery suite (referent group) or operating room was associated with a significantly higher risk of death: ICU/Post-Anesthesia Care Unit (PACU) (OR = 3.32 (95% CI, 2.00-5.52); p < 0.001) and ER/other (OR = 1.89 (95% CI, 1.15-3.11); p = 0.012). While MCA cases with a shockable vs. non-shockable first documented pulseless rhythm had similar outcomes, those with an indeterminate rhythm were less likely to die, (OR = 0.41(95% CI, 0.20-0.84); p = 0.014). In a sensitivity analysis, removal of the indeterminate group did not alter outcomes regarding first documented pulseless rhythm or arrest location. Area under the curve for the final model was 0.715 (95% CI 0.673-0.757).Conclusions: Our study identified several novel factors associated with IH death of our MCA cohort. More research is required to further understand the pathophysiologic dynamics affecting outcomes of IH MCA in this unique population. [ABSTRACT FROM AUTHOR]

Aim: Early detection of clinical deterioration on the wards may improve outcomes, and most early warning scores only utilize a patient's current vital signs. The added value of vital sign trends over time is poorly characterized. We investigated whether adding trends improves accuracy and which methods are optimal for modelling trends.Methods: Patients admitted to five hospitals over a five-year period were included in this observational cohort study, with 60% of the data used for model derivation and 40% for validation. Vital signs were utilized to predict the combined outcome of cardiac arrest, intensive care unit transfer, and death. The accuracy of models utilizing both the current value and different trend methods were compared using the area under the receiver operating characteristic curve (AUC).Results: A total of 269,999 patient admissions were included, which resulted in 16,452 outcomes. Overall, trends increased accuracy compared to a model containing only current vital signs (AUC 0.78 vs. 0.74; p<0.001). The methods that resulted in the greatest average increase in accuracy were the vital sign slope (AUC improvement 0.013) and minimum value (AUC improvement 0.012), while the change from the previous value resulted in an average worsening of the AUC (change in AUC -0.002). The AUC increased most for systolic blood pressure when trends were added (AUC improvement 0.05).Conclusion: Vital sign trends increased the accuracy of models designed to detect critical illness on the wards. Our findings have important implications for clinicians at the bedside and for the development of early warning scores. [ABSTRACT FROM AUTHOR]

Abstract: Background: When providing advanced life support (ALS) in cardiac arrest, the patient may alternate between four clinical states: ventricular fibrillation/tachycardia (VF/VT), pulseless electrical activity (PEA), asystole, and return of spontaneous circulation (ROSC). At the end of the resuscitation efforts, either death has been declared or sustained ROSC has been obtained. The aim of this study was to describe and analyze the clinical state transitions during ALS among patients experiencing in-hospital cardiac arrest. Methods and results: The defibrillator files from 311 in-hospital cardiac arrests at the University of Chicago Hospital (IL, USA) and St. Olav University Hospital (Trondheim, Norway) were analyzed (clinicaltrials.gov: NCT00920244). The transitions between clinical states were annotated along the time axis and visualized as plots of the state prevalence according to time. The cumulative intensity of the state transitions was estimated by the Nelson–Aalen estimator for each type of state transition, and for the intensities of overall state transitions. Between 70% and 90% of patients who eventually obtained sustained ROSC had progressed to ROSC by approximately 15–20min of ALS, depending on the initial rhythm. Patients behaving unstably after this time period, i.e., alternating between ROSC, VF/VT and PEA, had a high risk of ultimately being declared dead. Conclusions: We provide an overall picture of the intensities and patterns of clinical state transitions during in-hospital ALS. The majority of patients who obtained sustained ROSC obtained this state and stabilized within the first 15–20min of ALS. Those who continued to behave unstably after this time point had a high risk of ultimately being declared dead. [Copyright &y& Elsevier]

Abstract: Background: Clinical deterioration of ward patients can result in intensive care unit (ICU) transfer, cardiac arrest (CA), and/or death. These different outcomes have been used to develop and test track and trigger systems, but the impact of outcome selection on the performance of prediction algorithms is unknown. Methods: Patients hospitalized on the wards between November 2008 and August 2011 at an academic hospital were included in the study. Ward vital signs and demographic characteristics were compared across outcomes. The dataset was then split into derivation and validation cohorts. Logistic regression was used to derive four models (one per outcome and a combined outcome) for predicting each event within 24h of a vital sign set. The models were compared in the validation cohort using the area under the receiver operating characteristic curve (AUC). Results: A total of 59,643 patients were included in the study (including 109 ward CAs, 291 deaths, and 2638 ICU transfers). Most mean vital signs within 24h of the events differed statistically, with those before death being the most deranged. Validation model AUCs were highest for predicting mortality (range 0.73–0.82), followed by CA (range 0.74–0.76), and lowest for predicting ICU transfer (range 0.68–0.71). Conclusions: Despite differences in vital signs before CA, ICU transfer, and death, the different models performed similarly for detecting each outcome. Mortality was the easiest outcome to predict and ICU transfer the most difficult. Studies should be interpreted with these differences in mind. [Copyright &y& Elsevier]

Abstract: Study aims: Hyperglycemia is associated with poor outcomes in critically ill patients. We examined blood glucose values following in-hospital cardiac arrest (IHCA) to (1) characterize post-arrest glucose ranges, (2) develop outcomes-based thresholds of hyperglycemia and hypoglycemia, and (3) identify risk factors associated with post-arrest glucose derangements. Methods: We retrospectively studied 17,800 adult IHCA events reported to the National Registry of Cardiopulmonary Resuscitation (NRCPR) from January 1, 2005 through February 1, 2007. Results: Data were available from 3218 index events. Maximum blood glucose values were elevated in diabetics (median 226mg/dL [IQR, 165–307mg/dL], 12.5mmol/L [IQR 9.2–17.0mmol/L]) and non-diabetics (median 176mg/dL [IQR, 135–239mg/dL], 9.78mmol/L [IQR 7.5–13.3mmol/L]). Unadjusted survival to hospital discharge was higher in non-diabetics than diabetics (45.5% [95% CI, 43.3–47.6%] vs. 41.7% [95% CI, 38.9–44.5%], p =0.037). Non-diabetics displayed decreased adjusted survival odds for minimum glucose values outside the range of 71–170mg/dL (3.9–9.4mmol/L) and maximum values outside the range of 111–240mg/dL (6.2–13.3mmol/L). Diabetic survival odds decreased for minimum glucose greater than 240mg/dL (13.3mmol/L). In non-diabetics, arrest duration was identified as a significant factor associated with the development of hypo- and hyperglycemia. Conclusions: Hyperglycemia is common in diabetics and non-diabetics following IHCA. Survival odds in diabetics are relatively insensitive to blood glucose with decreased survival only associated with severe (>240mg/dL, >13.3mmol/dL) hyperglycemia. In non-diabetics, survival odds were sensitive to hypoglycemia (<70mg/dL, <3.9mmol/L). [Copyright &y& Elsevier]

Background: Maternal mortality has risen in the United States in the twenty-first century, yet large cohort data of maternal cardiac arrest (MCA) are limited.Objective: We sought to describe contemporary characteristics and outcomes of in-hospital MCA.Methods: We queried the American Heart Association's Get with the Guidelines Resuscitation voluntary registry from 2000 to 2016 to identify cases of maternal cardiac arrest. All index cardiac arrests occurring in women aged 18-50 with a patient illness category designated as obstetric or location of arrest occurring in a delivery suite were included. Institutional review deemed that this research was exempt from ethical approval.Results: A total of 462 index events met criteria for MCA, with a mean age of 31 ± 7 years and a racial distribution of: 49.4% White, 35.3% Black and 15.3% Other/Unknown. While 32% had no pre-existing conditions or physiologic disorders, respiratory insufficiency (36.1%) and hypotension/hypoperfusion (33.3%) were the most common antecedent conditions. In most cases, the first documented pulseless rhythm was non-shockable; pulseless electrical activity (50.8%) or asystole (25.6%). Only 11.7% presented with a shockable rhythm; ventricular fibrillation (6.5%) or pulseless ventricular tachycardia (5.2%) while the initial pulseless rhythm was unknown in 11.9% of cases. Return of spontaneous circulation occurred in 73.6% but 68 (14.7%) had more than one arrest. The rate of survival to discharge was 40.7% overall; 37.3% with non-shockable rhythms, 33% with shockable rhythms and 64.3% with unknown presenting rhythms.Conclusions: Maternal survival at hospital discharge in this cohort was less than 50%, lower than rates reported in other epidemiological datasets. More research is required in maternal resuscitation science and translational medicine to continue to improve outcomes and understand maternal mortality. [ABSTRACT FROM AUTHOR]

Aim: The American Heart Association (AHA) recommends monitoring cardiopulmonary resuscitation (CPR) quality using end tidal carbon dioxide (ETCO2) or invasive hemodynamic data. The objective of this study was to evaluate the association between clinician-reported physiologic monitoring of CPR quality and patient outcomes.Methods: Prospective observational study of index adult in-hospital CPR events using the AHA's Get With The Guidelines - Resuscitation Registry. Physiologic monitoring was defined using specific database questions regarding use of either ETCO2 or arterial diastolic blood pressure (DBP) to monitor CPR quality. Logistic regression was used to evaluate the association between physiologic monitoring and outcomes in a propensity score matched cohort.Results: In the matched cohort, (monitored n=3032; not monitored n=6064), physiologic monitoring of CPR quality was associated with a higher rate of return of spontaneous circulation (ROSC; OR 1.22, CI95 1.04-1.43, p=0.017) compared to no monitoring. Survival to hospital discharge (OR 1.04, CI95 0.91-1.18, p=0.57) and survival with favorable neurological outcome (OR 0.97, CI95 0.75-1.26, p=0.83) were not different between groups. Of index events with only ETCO2 monitoring indicated (n=803), an ETCO2 >10mmHg during CPR was reported in 520 (65%), and associated with improved survival to hospital discharge (OR 2.41, CI95 1.35-4.30, p=0.003), and survival with favorable neurological outcome (OR 2.31, CI95 1.31-4.09, p=0.004) compared to ETCO2 ≤10mmHg.Conclusion: Clinician-reported use of either ETCO2 or DBP to monitor CPR quality was associated with improved ROSC. An ETCO2 >10mmHg during CPR was associated with a higher rate of survival compared to events with ETCO2 ≤10mmHg. [ABSTRACT FROM AUTHOR]

Objective Cardiopulmonary resuscitation (CPR) guidelines recommend the administration of chest compressions (CC) at a standardized rate and depth without guidance from patient physiologic output. The relationship between CC performance and actual CPR-generated blood flow is poorly understood, limiting the ability to define “optimal” CPR delivery. End-tidal carbon dioxide (ETCO 2 ) has been proposed as a surrogate measure of blood flow during CPR, and has been suggested as a tool to guide CPR despite a paucity of clinical data. We sought to quantify the relationship between ETCO 2 and CPR characteristics during clinical resuscitation care. Methods Multicenter cohort study of 583 in- and out-of-hospital cardiac arrests with time-synchronized ETCO 2 and CPR performance data captured between 4/2006 and 5/2013. ETCO 2 , ventilation rate, CC rate and depth were averaged over 15-s epochs. A total of 29,028 epochs were processed for analysis using mixed-effects regression techniques. Results CC depth was a significant predictor of increased ETCO 2 . For every 10 mm increase in depth, ETCO 2 was elevated by 1.4 mmHg ( p < .001). For every 10 breaths/min increase in ventilation rate, ETCO 2 was lowered by 3.0 mmHg ( p < .001). CC rate was not a predictor of ETCO 2 over the dynamic range of actual CC delivery. Case-averaged ETCO 2 values in patients with return of spontaneous circulation were higher compared to those who did not have a pulse restored (34.5 ± 4.5 vs 23.1 ± 12.9 mmHg, p < .001). Conclusions ETCO 2 values generated during CPR were statistically associated with CC depth and ventilation rate. Further studies are needed to assess ETCO 2 as a potential tool to guide care. [ABSTRACT FROM AUTHOR]

Aim To define the racial differences present after PEA and asystolic IHCA and explore factors that could contribute to this disparity. Methods We analyzed PEA and asystolic IHCA in the Get-With-The-Guidelines-Resuscitation database. Multilevel conditional fixed effects logistic regression models were used to estimate the relationship between race and survival to discharge and return of spontaneous circulation (ROSC), sequentially controlling for hospital, patient demographics, comorbidities, arrest characteristic, process measures, and interventions in place at time of arrest. Results Among the 561 hospitals, there were 76,835 patients who experienced IHCA with an initial rhythm of PEA or asystole (74.8% white, 25.2% black). Unadjusted ROSC rate was 55.1% for white patients and 54.1% for black patients (unadjusted OR: 0.94 [95% CI, 0.90–0.98], p = 0.016). Survival to discharge was 12.8% for white patients and 10.4% for black patients (unadjusted OR: 0.83 [95% CI, 0.78–0.87], p < 0.001). After adjusting for temporal trends, patient characteristics, hospital, and arrest characteristics, there remained a difference in survival to discharge (OR: 0.85 [95% CI, 0.79–0.92]) and rate of ROSC (OR: 0.88 [95% CI, 0.84–0.92]). Black patients had a worse mental status at discharge after survival. Rates of DNAR placed after survival from were lower in black patients with a rate of 38.3% compared to 44.5% in white patients ( p < 0.001). Conclusion Black patients are less likely to experience ROSC and survival to discharge after PEA or asystole IHCA. Individual patient characteristics, event characteristics, and hospital characteristics don’t fully explain this disparity. It is possible that disease burden and end-of-life preferences contribute to the racial disparity. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Conventional paper-based resuscitation transcripts are notoriously inaccurate, often lacking the precision that is necessary for recording a fast-paced resuscitation. The aim of this study was to evaluate whether a tablet computer-based application could improve upon conventional practices for resuscitation documentation. Methods: Nurses used either the conventional paper code sheet or a tablet application during simulated resuscitation events. Recorded events were compared to a gold standard record generated from video recordings of the simulations and a CPR-sensing defibrillator/monitor. Events compared included defibrillations, medication deliveries, and other interventions. Results: During the study period, 199 unique interventions were observed in the gold standard record. Of these, 102 occurred during simulations recorded by the tablet application, 78 by the paper code sheet, and 19 during scenarios captured simultaneously by both documentation methods These occurred over 18 simulated resuscitation scenarios, in which 9 nurses participated. The tablet application had a mean sensitivity of 88.0% for all interventions, compared to 67.9% for the paper code sheet (P =0.001). The median time discrepancy was 3s for the tablet, and 77s for the paper code sheet when compared to the gold standard (P <0.001). Conclusions: Similar to prior studies, we found that conventional paper-based documentation practices are inaccurate, often misreporting intervention delivery times or missing their delivery entirely. However, our study also demonstrated that a tablet-based documentation method may represent a means to substantially improve resuscitation documentation quality, which could have implications for resuscitation quality improvement and research. [Copyright &y& Elsevier]

Abstract: Aim: Advanced simulation tools are increasingly being incorporated into cardiopulmonary resuscitation (CPR) training. These educational methods have been shown to improve trainee performance in simulated settings, but translation into clinical practice remains unknown for many aspects of CPR quality. This study attempts to measure the impact of simulation-based training for resuscitation team leaders on some measures of CPR quality during actual in-hospital resuscitation attempts. Methods: In this prospective, randomized interventional cluster trial, internal medicine resident physicians (post-graduate year 2) were randomized using a random number generator to participate in a 4-h, immersive simulation course in cardiopulmonary resuscitation leadership using a high-fidelity simulator with video debriefing prior to serving as resuscitation team leaders at an academic medical center. Objective metrics of actual resuscitation performance were obtained from a CPR-sensing monitor/defibrillator. Results: Thirty-two residents were randomized to receive simulation training or no additional training between April and July 2007 and data were collected following 98 actual resuscitations between July 2007 and June 2008. CPR quality from resuscitations led by 14 simulation-trained and 16 control group residents was similar in terms of mean compression depth (48 vs 49mm; p =0.53); compression rate (107 vs 104min−1; p =0.30); ventilation rate (12 vs 12min−1; p =0.45) and no-flow fraction (0.08 vs 0.07; p =0.34). Conclusions: Although we failed to detect any significant differences in objective measures of CPR quality, we have demonstrated that CPR-sensing technology has the potential for use in assessing the impact of a simulation curriculum on some aspects of actual resuscitation performance. A larger study, performed in a setting with lower baseline performance, would be required to assess the specific simulation curriculum. [Copyright &y& Elsevier]

Abstract: Objective: While the use of therapeutic hypothermia (TH) has improved outcomes after resuscitation from cardiac arrest, prognostication of survival and neurologic function remains difficult during the post-arrest time period. Bispectral index (BIS) monitoring, a non-invasive measurement of simplified electroencephalographic data, is increasingly being considered for post-arrest neurologic assessment and outcomes prediction, although data supporting the technique are limited. We hypothesized that BIS values within 24h after resuscitation would correlate with neurologic outcomes at discharge. Methods: We prospectively collected BIS data in consecutive patients initially resuscitated from cardiac arrest and treated with TH in one academic medical center. We assessed BIS values in context of cerebral performance category (CPC) assessment on the day of discharge. Results: Data were collected in 62 post-arrest patients, of whom 26/62 (42%) survived to hospital discharge. Mean BIS values at 24h post-resuscitation were significantly different in the survivors with CPC 1–2 (“good” outcome) vs those with CPC 3–5 (“poor” outcome) or death during hospitalization (49±13 vs 30±20; p <0.001). Receiver operator characteristic analysis suggested that 24h BIS was most predictive of CPC 1–2 outcome compared to the other timepoints; a BIS cutpoint of 45 exhibited a sensitivity of 63% and a specificity of 86%, with a positive likelihood ratio of 4.67. Sixteen patients exhibited a BIS of zero during at least one timepoint; all of these patients died during hospitalization. Conclusions: BIS monitoring values at 24h post-resuscitation are correlated with neurologic outcomes in patients undergoing TH treatment. In 16/62 patients, a BIS of zero at any timepoint was observed, which was uniformly correlated with poor outcome after resuscitation from cardiac arrest; however, a non-zero BIS is insufficient as a sole predictor of good neurologic survival. [Copyright &y& Elsevier]