PhD in the spotlight

PHILIPPE DEWOLF

Cardiac arrest is a dynamic condition, presenting a significant challenge that tests the technical and non-technical skills of healthcare personnel to their limits. This manuscript primarily explores the role of Advanced Cardiovascular Life Support (ACLS) in the chain of survival. ACLS relies on algorithms that delineate each step in terms of content and timing. Despite evidence-based ACLS guidelines emphasizing the quality of CPR, there remain several issues regarding CPR quality during cardiac arrest, necessitating additional efforts to improve adherence to these guidelines among resuscitation teams.

To this end, we investigated potential areas for improvement and the gaps encountered in daily practice, as well as how actual performance diverges from guideline recommendations. The ProRea Study is the first to video record cardiac arrests outside the emergency setting, allowing for a detailed prospective examination of all critical steps during resuscitation performed by Mobile Medical Teams (MMTs). We first confirmed that the awareness of being observed did not influence team behavior, effectively refuting the 'Hawthorne effect' or 'observer effect'. This validation indicates that video recording, under the conditions of our study, can be safely used as a tool for analyzing cardiac arrest performance, offering significant value in data registration and quality monitoring.

Through the analysis of these recordings, we assessed adherence to guidelines for crucial steps in the ACLS algorithm. We identified potentially avoidable factors responsible for interruptions in chest compressions, investigated the search for reversible causes, and evaluated the coordination of time-critical actions. Additionally, we examined how teamwork, leadership, and communication impact healthcare professionals' performance in real-life resuscitations.

Despite the understanding that minimizing interruptions in chest compressions is critical for maintaining coronary and cerebral perfusion pressure and increasing the chance of Return of Spontaneous Circulation (ROSC), challenges in reducing hands-off time persist. We found that 33% of CPR interruptions exceeded the recommended 10 seconds, with the most common reasons being prolonged rhythm checks, incorrect use of mechanical chest compression devices, changes in personnel performing compressions, and tracheal intubation.

There is an urgent need to make prehospital healthcare workers aware of time losses during critical actions. Time-sensitive training could enhance awareness and optimize daily practice. Our observations revealed that more than 75% of out-of-hospital cardiac arrests deviated from guidelines. Regarding airway management, the initial endotracheal intubation success rate was 69.5%. In 20.3% of resuscitations, more than two attempts were needed for intubation, and in 25.8%, chest compressions were interrupted for over 10 seconds. Capnography was used in only 63% of intubations. Additionally, epinephrine and amiodarone were frequently administered before the third shock, contrary to ACLS recommendations.

In approximately one-fourth of the recorded resuscitations, MMTs did not perform an etiologic evaluation. When conducted, the median time from arrival to start of evaluation was 4 minutes for out-of-hospital cardiac arrests (OHCA) and 4 minutes 15 seconds for in-hospital cardiac arrests (IHCA). In 80% of evaluations, emergency physicians employed the 4Hs and 4Ts system. Heteroanamnesis and medical history questioning were the preferred methods, while clinical examinations and technical investigations were less commonly used. MMTs often failed to initiate treatment promptly, taking up to twice the recommended time, which underscored the significant correlation between timely etiologic evaluation and ROSC.

A systematic review assessed the impact of non-technical skills (NTS) training on performance in ACLS simulations, demonstrating that team simulation training improves NTS and reduces the time to complete a simulated cardiac arrest. Feedback during debriefing and repetitive practice were identified as crucial elements for training NTS, although the benefits persisted for only about 3 to 6 months.

The analysis of CA video recordings using the validated Team Emergency Assessment Measure (TEAM) tool revealed that effective team communication scored the lowest, whereas composure, control, and adherence to guidelines scored the highest. The results from the ProRea study will inform recommendations for optimal ACLS training for healthcare providers.

Emphasizing a time-specific approach during simulation training is vital. Recognizing areas for improvement is a crucial first step. Enhancing the Chest Compression Fraction (CCF) through targeted training on specific technical activities is essential. Additionally, the approach to etiologic evaluation needs further exploration to streamline and potentially incorporate technical aids like ultrasound.

Articles:

* Dewolf P, Rutten B, Wauters L, van den Bempt S, Uten T, van Kerkhoven J, et al. Impact of video-recording on patient outcome and data collection in out-of-hospital cardiac arrests. Resuscitation 2021;165:1–7. https://doi.org/10.1016/j.resu....

* Dewolf P, Wauters L, Clarebout G, van den Bempt S, Uten T, Desruelles D, et al. Assessment of chest compression interruptions during advanced cardiac life support. Resuscitation 2021;165:140–7. https://doi.org/10.1016/j.resu....

* Dewolf P, Wauters L, Clarebout G, Elen J. Timing and identification of the cause and treatment of a cardiac arrest: a potential survival benefit? Med Princ Pract 2022. https://doi.org/10.1159/000525....

* Dewolf P, Clarebout G, Wauters L, van Kerkhoven J, Verelst S. The Effect of Teaching Nontechnical Skills in Advanced Life Support: A Systematic Review. AEM Educ Train 2020:aet2.10522. https://doi.org/10.1002/aet2.1....

* Dewolf P, Vanneste M, Desruelles D, Wauters L. Measuring non-technical skills during prehospital advanced cardiac life support: A pilot study. Resusc Plus 2021;8:100171. https://doi.org/10.1016/J.RESP....

* van den Bempt S, Wauters L, Dewolf P. Pulseless electrical activity: Detection of underlying causes in a prehospital setting. Medical Principles and Practice 2021;30:212–22. https://doi.org/10.1159/000513....

* Dewolf P, Arnout PJ, van den Bempt S, Uten T, Loots K, Wauters L. When time is of the essence: comparison of the resuscitation time frame recommended by the ALS guidelines and daily practice. https://doi.org/10.29011/2475-...