- Email: [email protected]
Development of a reliable questionnaire in resuscitation knowledge
Correspondence
723
initial dose: adult 1 to 2 mg IV, children 0.05 mg/kg IV; repeated until signs of atropinization; then pralidoxime 25 to 50 mg/kg (up to 2 g) IV slowly Q6H (according to the guideline of Veterans General Hospital, Taichung, Taiwan). In our clinical experience, that dosage is adequate in Asian populations. Otherwise, the therapeutic protocol that was mentioned in our article (our hospital) is just a general rule, but it also can be adjusted according to the clinical manifestations in acute OP patients. The study of Pawar et al study is the first randomised trial that include large doses of pralidoxime and suggests that higher doses would be superior to the lower doses (b6 g/d) intermittent bolus that is most commonly used in Asia [5]. Our study subjects were performed between July 1996 and Aug 2005; the therapeutic protocol was not available in the studied period. The therapeutic protocol that we provided is still being used in Taiwan. Jiung-Hsiun Liu MD Che-Yi Chou MD Ya-Fei Yang MD Division of Nephrology Department of Internal Medicine China Medical University Hospital Taichung, Taiwan E-mail address: [email protected] doi:10.1016/j.ajem.2008.03.039
References [1] Brill SA, Stewart TR, Brundage SI, et al. Base deficit does not predict mortality when secondary to hyperchloremic acidosis. Shock 2002;17:459-62. [2] Hatherill M, Waggie Z, Purves L, et al. Mortality and the nature of metabolic acidosis in children with shock. Intensive Care Med 2003;29:286-91. [3] Kregenow DA, Rubenfeld GD, Hudson LD, et al. Hypercapnic acidosis and mortality in acute lung injury. Crit Care Med 2006;34:1-7. [4] Robertson R, Eidt J, Bitzer L, et al. Severe acidosis alone does not predict mortality in the trauma patient. Am J Surg 1995;170:691-4 [discussion 694-695]. [5] Pawar KS, Bhoite RR, Pillay CP, et al. Continuous pralidoxime infusion versus repeated bolus injection treat organophosphorus pesticide poisoning: a randomised controlled trial. Lancet 2006;368: 2136-41.
Development of a reliable questionnaire in resuscitation knowledge To the Editor, The first cardiopulmonary resuscitation (CPR) instruction for health care professionals dates back to 1966 in the United States [1]. A resuscitation training program was introduced in Sweden by the Swedish Society of Cardiology
in 1984. According to guidelines, all health care professionals should be able to perform basic life support, including defibrillation with a semiautomated external defibrillator [2-4]. The possibility to survive a cardiac arrest depends on how quick interventions are made from people around the patient [5]. An expert panel from the Swedish Society of Cardiology has developed a CPR education program. This training program includes study questions for testing the rescuers' knowledge in CPR [6,7]. The European Resuscitation Council has developed an education program [8] and 2 multiple-choice questionnaires [9] in English for the advanced life support course. This makes it possible to evaluate the theoretical knowledge in advanced CPR in 1 hour. We undertook this study to develop a more condensed but reliable multiple-choice questionnaire for the course in basic life support with a semiautomated external defibrillator. The study was approved by the Regional Ethics Committee in Sweden (Dnr 2006/201). All participants (42 professionals) were from different wards from 2 hospitals in Sweden. The mean age of the respondents was 42.1. Their mean work experience was 20.3 years. The questionnaire was designed to retrieve information about health care professional's theoretical knowledge in CPR. There is no completely objective method of establishing face validity, but using expert panel opinion is one way [10]. An expert panel from the Swedish Society of Cardiology developed the study questions. The questionnaire will cover (1) evaluation of an unconscious patient, (2) evaluation of a suspect cardiac arrest, (3) chest compressions, (4) mouth-to-mouth ventilation, (5) who is allowed to defibrillate, (6) indications for defibrillation, (7) the time frame for optimal defibrillation, (8) practical procedure in defibrillation, and (9) how to proceed when practical problems. To ensure clarity and reliability of the questionnaire, we asked 21 health care professionals to complete the questionnaire. To ensure stability, they completed the same questionnaire again after 6 to 10 days. Their responses and comments were then analysed; resulting in a new version design according to guidelines [11]. Then, the rewritten questionnaire was completed by another 21 health care professionals twice. Four participants were interviewed between the first and second questionnaire to ensure that the questions were consistently apprehended. The evolution of each question is presented (Table 1). Analyses of the questionnaire and the respondent's written comments resulted in several modifications, for example, adding the response alternative “don't know” to all questions and adding categories to 2 questions concerning the rate of external chest compressions (compressions per minute) and the allowed time to examine the patient (seconds). The interviews gave the 4 respondents an opportunity to reflect on each question, resulting in some amendments of wording (Table 2), and 2 questions were omitted.
724 Table 1
Correspondence The evolution of the questionnaire from the respondent's written reactions and their opinions/suggestions in interviews
Question
First version
Second version
Final version
1
What do you do if you see a person tumble in the waiting room?
What do you do if you see a person tumble in the waiting room at your hospital where you work? Response alternative: Same as in the first version but e-alternative is added e. Don't know
What is the first thing you do if you see a person tumble in the waiting room at your hospital where you work? No change in response alternative.
How long time (in seconds) can your inspection of a patient with suspected cardiac arrest take?
No change.
2
3
4
Response alternative: a. Lay the person in recovery position b. Check for response, breathing and pulse c. Give 2 breaths as soon as possible d. Check for response and breathing How long time can your inspection of a patient with suspected cardiac arrest take? Response alternative: a. 10-20 s b. 60 s c. 15 s d. 30 s Which first aid equipment should you prioritize, if you can't get all first aid equipment at once? Response alternative: a. Defibrillator b. Heart board c. Suction equipment d. ECG appliance e. Oxygen equipment f. Pocket mask Can anyone use an automated external defibrillator (AED)? Response alternative: a. It gives the biggest chance to survive. b. It is the least dangerous thing you can do. c. It is the easiest thing you can do.
5
d. It is both easy and more hygienic to use the (AED) than perform CPR. When should you use a defibrillator? Response alternative: a. When the patient looks grey and dead b. When the patient says that he thinks it is the only thing that helps
Response alternative: a. 10-15 s b. 20 s c. 30 s d. 60 s e. Don't know No change.
Response alternative: Same as in the first version but g-alternative is added g. Don't know
Can health care professionals working at a hospital use an automatic external defibrillator? Response alternative: a. Yes, everybody is allowed to do so b. Yes but only persons who has passed a CPR course with an AED c. Yes, but only health care professionals who has passed a course in CPR with an AED and got a written delegation d. Don't know
No change.
At which arrhythmias should you defibrillate during ongoing CPR? Write down you answer.
At which arrhythmias should you defibrillate during ongoing CPR? Response alternatives are the following arrhythmias: a. Ventricular fibrillation b. Asystoli
Correspondence
725
Table 1 (continued) Question
First version
Second version
c. When the patient is unconscious, don't breath or have pulse d. When I can't do CPR
6
The electrodes should be placed, where? Response alternative:
7
a. Both between the nipples b. One below right clavicle and the other 10 cm below left armpit c. One at the chest and the other at the back d. One on each side of the chest The patient is soaking wet of cold sweat, what should you do? Response alternatives: a. Nothing special b. Let the clothes be on c. Put dry paper on the skin and put the electrodes on d. Dry the area where the plats should be placed and the area between the plates
8
How many times can you defibrillate without doing anything else in between? Response alternatives: a. 2 times b. 3 times c. No limit d. Maximum 1 defibrillation at the time, then you have to do CPR
9
The question did not exist.
10
When you give breath you should?
Response alternatives: a. Give breath slowly to avoid that you get tired b. Breath slowly to avoid the air to get to the patients stomach
Final version c. Ventricular tachycardia
Where should the electrodes from the defibrillator be placed on the patient during CPR? Same as in the first version but e-alternative is added e. Don't know
The patient is soaking wet of cold sweat, what should you do to be able to defibrillate? Response alternative: a. No change b. No change c. No change d. Dry the area where the electrode plats should be placed and the area between the plates e. Don't know How many times in one sequence can you defibrillate during ongoing CPR? Response alternatives: a. Maximum 1 defibrillation at the time, then you have to do CPR b. 2 times then you have to do CPR c. 3 times then you have to do CPR d. No limit e. Don't know Write down how soon in minutes the patient should be defibrillated if the patient have a ventricular fibrillation? Write down your answer.
In connection with CPR when you make breath/ventilate the patient you should? Response alternatives: a. Breath/ventilate slowly b. Breath/ventilate strongly
d. Pulse less electric activity The response alternatives for each arrhythmia are Yes, No and Don't know. No change.
No change.
No change.
The patient has ventricular fibrillation at the first rhythm section. How soon should you defibrillate according to the existing guidelines? Response alternatives: a. Within 1 min b. Within 2 min c. Within 3 min d. Within 4 min e. Within 5 min f. Don't know No change.
726
Correspondence
Table 1 (continued) Question
11
12
First version
Second version
c. Give small breaths with fast rate d. Breath faster if you recognize that the patient start to cough and breath How do you know that your breaths are effective? Response alternative:
c. Breath/ventilate fast d. Don't know
a. You can feel the air get back through the mouth b. You can feel the air disappear in the patient c. You see the chest rising d. You can hear a hissing sound At which frequency should you do chest compression? Respond alternatives: a. 60 b. 80-100 c. 100 d. More than 100
13
14
Which of the presented professional categories below represents you? Response alternative: a. Assistant nurse b. Nurse, midwife c. Laboratory assistant d. Physiotherapist e. Occupational therapist f. Audionom g. Doctor h. Other professional category, please write it down For how long have you been working as a health care professional? Write down your answer.
Final version
How do you know that the breath/ventilation is effective? Same as in the first version but e-alternative is added e. Don't know
No change.
With witch frequency (in minutes) shall you perform chest compressions? Respond alternatives: a. 60 b. 80 c. 100 d. More than 100 e. Don't know No change.
No change.
For how long have you all in all been working as a health care professional? Write down your answer.
No change.
No change.
ECG indicates electrocardiogram.
The rate of correct responses and the Raw Agreement Measure before and after corrections of the questionnaire are presented in Table 3. The increase in the rate of correct responses was 4.9 percentage points from the first to the second version. Calculations with the Raw Agreement Measure demonstrated an increase in agreement with 1.9 percentage points. Although influence by chance cannot be excluded because of the small sample size, high values in most questions indicated a reliable final questionnaire. Questions 5 and 9 had the lowest agreement measures and were reformulated to questions with response alternatives. Our impression was that many respondents lack the specific
knowledge for correct answers. Question 5, concerning which arrhythmia should be defibrillated, might be eliminated. The capacity of semiautomatic defibrillators will make this specific knowledge pointless. The advantage with a limited questionnaire is that the response time will be short. Thus, a large group may quickly answer the questions with a short feedback time and limited needs for administration. Strict selection of the questions may reduce the risk of loosing important information. However, a low “cost” is that we then loose control of internal consistency. Yet, with high face validity, given that the questions were constructed by experts with careful selection of the questions and with
good equivalence, we consider the questionnaire to be highly reliable and valid. Concerning specific knowledge, low values of correct responses were observed in question 12 in both groups of respondents, indicating the need of education in CPR rather than an imbalance between the key and the distractors or low face validity. There are no significant changes between both groups in correct answers; this indicates a reliable questionnaire. This new short reliable questionnaire is to be used for evaluation of knowledge in CPR before and after education. Potentially, it may be the national standard questionnaire for such testing.
bIf you mean anybody, it can be any person who is at the hospital. I think that you mean professionals working at the hospital, that's how I thought about the question.” “I think you should use the word place instead of put steady because then it doesn't matter what kind of defibrillator electrodes you have.”
Marie-Louise Södersved Källestedt RN Jerzy Leppert MD Mats Enlund MD Centre for Clinical Research Central Hospital Västerås SE-721 89, Sweden E-mail address: [email protected] Johan Herlitz MD Division of Cardiology Sahlgrenska University Hospital Göteborg, Sweden doi:10.1016/j.ajem.2008.02.015
References
ECG indicates electrocardiogram.
“Do you mean the ECG electrode or the defibrillator electrode, as the question is formulated now—I don't know which electrodes you mean.” No. 6. The electrodes should be placed, where?
“My answer are under right clavicle and the other electrode 10 cm below left armpit, it was easy to answer, no hard to understand.”
bYes, I do understand the question, but I don't know the difference in advanced CPR and AED CPR. That makes me unsure if the right alternative needs a written delegation.” “I thought of the electrodes from the defibrillator, now when I think about it more—did you mean the ECG electrodes?” bI do understand the question, but I don't know the difference between a defibrillator and an AED.” No. 4. Can anyone use an automated external defibrillator (AED)?
bI think I understand the question—can all of us working at the hospital use an AED? But I 'm not sure about the answer.”
Interview 2 Interview 1
Interview 3
727
Question
Table 2
A matrix viewing examples from the respondent's spontaneous response to specific questions in their own words
Interview 4
Correspondence
[1] Wik L. Automatic and manual mechanical external chest compression devices for cardiopulmonary resuscitation. Resuscitation 2000;47: 7-25. [2] Makinen M, Castren M, Tolska T, Nurmi J, Niemi-Murola L. Teaching basic life support to nurses. Eur J Anaesthesiol 2006;23:327-31. [3] 2005 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 3: defibrillation. Resuscitation 2005;67: 203-11. [4] Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 4: the automated external defibrillator: key link in the chain of survival. The American Heart Association in Collaboration with the International Liaison Committee on Resuscitation. Circulation 2000;102:60-76. [5] Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the “chain of survival” concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991;83:1832-47. [6] D-HLR med halvautomatisk defibrillator3:e ed. Göteborg: Stiftelsen för HLR, Svenska Cardiologföreningen; 2001. [7] S-HLR, HLR för sjukvårdspersonal. Instruktörsbok1:a ed. . Göteborg: Stiftelsen för HLR, Svenska rådet för hjärt-lungräddning; 2006. [8] Teaching adults resuscitation. Antwerpen, Belgium: European Resuscitation Council; 2007. [9] Beaman A, Barnes P, Klentz B, McQuirk B. Increasing helping rates through information dissemination: teaching pays. Pers Soc Psychol Bull 1978;4:406-11. [10] Polit DF, Hungler BP. Nursing research: principles and methods. Philaselphia: Lippincott Williams & Williams; 1999.
728
Correspondence
Table 3 The rate of correct response and the Raw Agreement Measure on each question when presented to 2 different groups of 21 respondents before and after corrections of single questions in a questionnaire concerning knowledge in heart-lung resuscitation Question
1 2 3 4 5 6 7 8 9 10 11 12 13 14 Average a
Rate of correct response, first group (%)
Rate of correct response, second group (%)
Raw Agreement Measure, first group (%)
Raw Agreement Measure, second group (%)
No. of respondents answering “Don't know”
No. of respondents who didn't give any response
2:1
2:2
1:1
1:2
2:1
2:2
100 52 47 85 NA 66 76 42 NA 47 100 42 100 85 70.2
100 57 76 80 50 80 76 57 14 61 100 38 100 76 75.1
100 85 80 95 NA 100 84 78 NA 90 100 90 100 90 91.0
100 85 95 100 71 100 90 95 61 85 100 85 100 80 92.9
– – – 3 4 3 3 4 6 1 – 1 – –
– 1 – 3 5 3 2 4 5 – – 1 – –
– – – – – – 2 2 – – – – – 2
– – – – – – 2 2 – – – – – 2
– – – – 1 – – – 1 3 – – – 2
– – – – 1 – – – 2 – – – – 2
Note: The rate of correct response indicates correct response at both occasions (6-10 days in between) for the 2 groups of respondents. Raw Agreement Measure indicates the agreement in the response irrespective of right or wrong response. Don't know means that the respondents chose the response alternative “Don't know”. The response alternative “Don't know” was not available in the first version of the questionnaire. 1:1 indicates first version, first response; 1:2, first version, second response; 2:1, second version, first response; 2:2, second version, second response; NA, not available. a Not including questions 5 and 9.
[11] Masters JC, Hulsmeyer BS, Pike ME, Leichty K, Miller MT, Verst AL. Assessment of multiple-choice questions in selected test banks accompanying text books used in nursing education. J Nurs Educ 2001;40:25-32.
Should etomidate be used for rapid-sequence intubation induction in critically ill septic patients? Probably not To the Editor, Etomidate as an induction agent for critically ill patients was widely debated in the European intensive care and anesthesia literature in 2005 [1,2]. As Fengler describes, etomidate is well recognized to cause adrenal suppression in both elective surgical patients [3,4] and more profoundly in the critically ill. Adrenal suppression in this patient group is associated with increased mortality [5]. The use of steroid supplementation in severe sepsis and septic shock is still undecided, and CORTICUS has shown no benefit from the use of steroids in patients with or without evidence of adrenal axis suppression [6]. Etomidate use continues to be associated with a worse outcome and adrenal suppression [7-12]. Surely there can be no justification for using a drug
that is known to cause adrenal suppression, where this is associated with increased mortality and where other options exist. In sepsis, the volume of distribution of many drugs including induction agents is altered. Furthermore, in states of septic shock, blood is preferentially distributed to the vital organs, ultimately the brain and the heart. This will result in a greater concentration, than would be anticipated, of induction agent at its site of action. A reduced drug dose can therefore be administered. In severe sepsis and septic shock, cardiac output is also altered (increased or decreased), resulting in an altered circulation time. These factors in combination imply that a traditional approach to rapid sequence induction cannot be undertaken. In critically ill patients with sepsis, conventional induction agents result in significantly less cardiovascular instability if they are titrated slowly to effect rather than given on a dose per kilogram basis. When used in this way, significantly less drug is required. Cricoid pressure can still be applied throughout this process to prevent passive regurgitation of gastric contents. Both propofol (2,6-diisopropylphenol) and thiopentone sodium (sodium thiopental) can be used in this way. The concomitant use of liberal fluid resuscitation and, where necessary, vasopressors can prevent profound hypotension.
723
initial dose: adult 1 to 2 mg IV, children 0.05 mg/kg IV; repeated until signs of atropinization; then pralidoxime 25 to 50 mg/kg (up to 2 g) IV slowly Q6H (according to the guideline of Veterans General Hospital, Taichung, Taiwan). In our clinical experience, that dosage is adequate in Asian populations. Otherwise, the therapeutic protocol that was mentioned in our article (our hospital) is just a general rule, but it also can be adjusted according to the clinical manifestations in acute OP patients. The study of Pawar et al study is the first randomised trial that include large doses of pralidoxime and suggests that higher doses would be superior to the lower doses (b6 g/d) intermittent bolus that is most commonly used in Asia [5]. Our study subjects were performed between July 1996 and Aug 2005; the therapeutic protocol was not available in the studied period. The therapeutic protocol that we provided is still being used in Taiwan. Jiung-Hsiun Liu MD Che-Yi Chou MD Ya-Fei Yang MD Division of Nephrology Department of Internal Medicine China Medical University Hospital Taichung, Taiwan E-mail address: [email protected] doi:10.1016/j.ajem.2008.03.039
References [1] Brill SA, Stewart TR, Brundage SI, et al. Base deficit does not predict mortality when secondary to hyperchloremic acidosis. Shock 2002;17:459-62. [2] Hatherill M, Waggie Z, Purves L, et al. Mortality and the nature of metabolic acidosis in children with shock. Intensive Care Med 2003;29:286-91. [3] Kregenow DA, Rubenfeld GD, Hudson LD, et al. Hypercapnic acidosis and mortality in acute lung injury. Crit Care Med 2006;34:1-7. [4] Robertson R, Eidt J, Bitzer L, et al. Severe acidosis alone does not predict mortality in the trauma patient. Am J Surg 1995;170:691-4 [discussion 694-695]. [5] Pawar KS, Bhoite RR, Pillay CP, et al. Continuous pralidoxime infusion versus repeated bolus injection treat organophosphorus pesticide poisoning: a randomised controlled trial. Lancet 2006;368: 2136-41.
Development of a reliable questionnaire in resuscitation knowledge To the Editor, The first cardiopulmonary resuscitation (CPR) instruction for health care professionals dates back to 1966 in the United States [1]. A resuscitation training program was introduced in Sweden by the Swedish Society of Cardiology
in 1984. According to guidelines, all health care professionals should be able to perform basic life support, including defibrillation with a semiautomated external defibrillator [2-4]. The possibility to survive a cardiac arrest depends on how quick interventions are made from people around the patient [5]. An expert panel from the Swedish Society of Cardiology has developed a CPR education program. This training program includes study questions for testing the rescuers' knowledge in CPR [6,7]. The European Resuscitation Council has developed an education program [8] and 2 multiple-choice questionnaires [9] in English for the advanced life support course. This makes it possible to evaluate the theoretical knowledge in advanced CPR in 1 hour. We undertook this study to develop a more condensed but reliable multiple-choice questionnaire for the course in basic life support with a semiautomated external defibrillator. The study was approved by the Regional Ethics Committee in Sweden (Dnr 2006/201). All participants (42 professionals) were from different wards from 2 hospitals in Sweden. The mean age of the respondents was 42.1. Their mean work experience was 20.3 years. The questionnaire was designed to retrieve information about health care professional's theoretical knowledge in CPR. There is no completely objective method of establishing face validity, but using expert panel opinion is one way [10]. An expert panel from the Swedish Society of Cardiology developed the study questions. The questionnaire will cover (1) evaluation of an unconscious patient, (2) evaluation of a suspect cardiac arrest, (3) chest compressions, (4) mouth-to-mouth ventilation, (5) who is allowed to defibrillate, (6) indications for defibrillation, (7) the time frame for optimal defibrillation, (8) practical procedure in defibrillation, and (9) how to proceed when practical problems. To ensure clarity and reliability of the questionnaire, we asked 21 health care professionals to complete the questionnaire. To ensure stability, they completed the same questionnaire again after 6 to 10 days. Their responses and comments were then analysed; resulting in a new version design according to guidelines [11]. Then, the rewritten questionnaire was completed by another 21 health care professionals twice. Four participants were interviewed between the first and second questionnaire to ensure that the questions were consistently apprehended. The evolution of each question is presented (Table 1). Analyses of the questionnaire and the respondent's written comments resulted in several modifications, for example, adding the response alternative “don't know” to all questions and adding categories to 2 questions concerning the rate of external chest compressions (compressions per minute) and the allowed time to examine the patient (seconds). The interviews gave the 4 respondents an opportunity to reflect on each question, resulting in some amendments of wording (Table 2), and 2 questions were omitted.
724 Table 1
Correspondence The evolution of the questionnaire from the respondent's written reactions and their opinions/suggestions in interviews
Question
First version
Second version
Final version
1
What do you do if you see a person tumble in the waiting room?
What do you do if you see a person tumble in the waiting room at your hospital where you work? Response alternative: Same as in the first version but e-alternative is added e. Don't know
What is the first thing you do if you see a person tumble in the waiting room at your hospital where you work? No change in response alternative.
How long time (in seconds) can your inspection of a patient with suspected cardiac arrest take?
No change.
2
3
4
Response alternative: a. Lay the person in recovery position b. Check for response, breathing and pulse c. Give 2 breaths as soon as possible d. Check for response and breathing How long time can your inspection of a patient with suspected cardiac arrest take? Response alternative: a. 10-20 s b. 60 s c. 15 s d. 30 s Which first aid equipment should you prioritize, if you can't get all first aid equipment at once? Response alternative: a. Defibrillator b. Heart board c. Suction equipment d. ECG appliance e. Oxygen equipment f. Pocket mask Can anyone use an automated external defibrillator (AED)? Response alternative: a. It gives the biggest chance to survive. b. It is the least dangerous thing you can do. c. It is the easiest thing you can do.
5
d. It is both easy and more hygienic to use the (AED) than perform CPR. When should you use a defibrillator? Response alternative: a. When the patient looks grey and dead b. When the patient says that he thinks it is the only thing that helps
Response alternative: a. 10-15 s b. 20 s c. 30 s d. 60 s e. Don't know No change.
Response alternative: Same as in the first version but g-alternative is added g. Don't know
Can health care professionals working at a hospital use an automatic external defibrillator? Response alternative: a. Yes, everybody is allowed to do so b. Yes but only persons who has passed a CPR course with an AED c. Yes, but only health care professionals who has passed a course in CPR with an AED and got a written delegation d. Don't know
No change.
At which arrhythmias should you defibrillate during ongoing CPR? Write down you answer.
At which arrhythmias should you defibrillate during ongoing CPR? Response alternatives are the following arrhythmias: a. Ventricular fibrillation b. Asystoli
Correspondence
725
Table 1 (continued) Question
First version
Second version
c. When the patient is unconscious, don't breath or have pulse d. When I can't do CPR
6
The electrodes should be placed, where? Response alternative:
7
a. Both between the nipples b. One below right clavicle and the other 10 cm below left armpit c. One at the chest and the other at the back d. One on each side of the chest The patient is soaking wet of cold sweat, what should you do? Response alternatives: a. Nothing special b. Let the clothes be on c. Put dry paper on the skin and put the electrodes on d. Dry the area where the plats should be placed and the area between the plates
8
How many times can you defibrillate without doing anything else in between? Response alternatives: a. 2 times b. 3 times c. No limit d. Maximum 1 defibrillation at the time, then you have to do CPR
9
The question did not exist.
10
When you give breath you should?
Response alternatives: a. Give breath slowly to avoid that you get tired b. Breath slowly to avoid the air to get to the patients stomach
Final version c. Ventricular tachycardia
Where should the electrodes from the defibrillator be placed on the patient during CPR? Same as in the first version but e-alternative is added e. Don't know
The patient is soaking wet of cold sweat, what should you do to be able to defibrillate? Response alternative: a. No change b. No change c. No change d. Dry the area where the electrode plats should be placed and the area between the plates e. Don't know How many times in one sequence can you defibrillate during ongoing CPR? Response alternatives: a. Maximum 1 defibrillation at the time, then you have to do CPR b. 2 times then you have to do CPR c. 3 times then you have to do CPR d. No limit e. Don't know Write down how soon in minutes the patient should be defibrillated if the patient have a ventricular fibrillation? Write down your answer.
In connection with CPR when you make breath/ventilate the patient you should? Response alternatives: a. Breath/ventilate slowly b. Breath/ventilate strongly
d. Pulse less electric activity The response alternatives for each arrhythmia are Yes, No and Don't know. No change.
No change.
No change.
The patient has ventricular fibrillation at the first rhythm section. How soon should you defibrillate according to the existing guidelines? Response alternatives: a. Within 1 min b. Within 2 min c. Within 3 min d. Within 4 min e. Within 5 min f. Don't know No change.
726
Correspondence
Table 1 (continued) Question
11
12
First version
Second version
c. Give small breaths with fast rate d. Breath faster if you recognize that the patient start to cough and breath How do you know that your breaths are effective? Response alternative:
c. Breath/ventilate fast d. Don't know
a. You can feel the air get back through the mouth b. You can feel the air disappear in the patient c. You see the chest rising d. You can hear a hissing sound At which frequency should you do chest compression? Respond alternatives: a. 60 b. 80-100 c. 100 d. More than 100
13
14
Which of the presented professional categories below represents you? Response alternative: a. Assistant nurse b. Nurse, midwife c. Laboratory assistant d. Physiotherapist e. Occupational therapist f. Audionom g. Doctor h. Other professional category, please write it down For how long have you been working as a health care professional? Write down your answer.
Final version
How do you know that the breath/ventilation is effective? Same as in the first version but e-alternative is added e. Don't know
No change.
With witch frequency (in minutes) shall you perform chest compressions? Respond alternatives: a. 60 b. 80 c. 100 d. More than 100 e. Don't know No change.
No change.
For how long have you all in all been working as a health care professional? Write down your answer.
No change.
No change.
ECG indicates electrocardiogram.
The rate of correct responses and the Raw Agreement Measure before and after corrections of the questionnaire are presented in Table 3. The increase in the rate of correct responses was 4.9 percentage points from the first to the second version. Calculations with the Raw Agreement Measure demonstrated an increase in agreement with 1.9 percentage points. Although influence by chance cannot be excluded because of the small sample size, high values in most questions indicated a reliable final questionnaire. Questions 5 and 9 had the lowest agreement measures and were reformulated to questions with response alternatives. Our impression was that many respondents lack the specific
knowledge for correct answers. Question 5, concerning which arrhythmia should be defibrillated, might be eliminated. The capacity of semiautomatic defibrillators will make this specific knowledge pointless. The advantage with a limited questionnaire is that the response time will be short. Thus, a large group may quickly answer the questions with a short feedback time and limited needs for administration. Strict selection of the questions may reduce the risk of loosing important information. However, a low “cost” is that we then loose control of internal consistency. Yet, with high face validity, given that the questions were constructed by experts with careful selection of the questions and with
good equivalence, we consider the questionnaire to be highly reliable and valid. Concerning specific knowledge, low values of correct responses were observed in question 12 in both groups of respondents, indicating the need of education in CPR rather than an imbalance between the key and the distractors or low face validity. There are no significant changes between both groups in correct answers; this indicates a reliable questionnaire. This new short reliable questionnaire is to be used for evaluation of knowledge in CPR before and after education. Potentially, it may be the national standard questionnaire for such testing.
bIf you mean anybody, it can be any person who is at the hospital. I think that you mean professionals working at the hospital, that's how I thought about the question.” “I think you should use the word place instead of put steady because then it doesn't matter what kind of defibrillator electrodes you have.”
Marie-Louise Södersved Källestedt RN Jerzy Leppert MD Mats Enlund MD Centre for Clinical Research Central Hospital Västerås SE-721 89, Sweden E-mail address: [email protected] Johan Herlitz MD Division of Cardiology Sahlgrenska University Hospital Göteborg, Sweden doi:10.1016/j.ajem.2008.02.015
References
ECG indicates electrocardiogram.
“Do you mean the ECG electrode or the defibrillator electrode, as the question is formulated now—I don't know which electrodes you mean.” No. 6. The electrodes should be placed, where?
“My answer are under right clavicle and the other electrode 10 cm below left armpit, it was easy to answer, no hard to understand.”
bYes, I do understand the question, but I don't know the difference in advanced CPR and AED CPR. That makes me unsure if the right alternative needs a written delegation.” “I thought of the electrodes from the defibrillator, now when I think about it more—did you mean the ECG electrodes?” bI do understand the question, but I don't know the difference between a defibrillator and an AED.” No. 4. Can anyone use an automated external defibrillator (AED)?
bI think I understand the question—can all of us working at the hospital use an AED? But I 'm not sure about the answer.”
Interview 2 Interview 1
Interview 3
727
Question
Table 2
A matrix viewing examples from the respondent's spontaneous response to specific questions in their own words
Interview 4
Correspondence
[1] Wik L. Automatic and manual mechanical external chest compression devices for cardiopulmonary resuscitation. Resuscitation 2000;47: 7-25. [2] Makinen M, Castren M, Tolska T, Nurmi J, Niemi-Murola L. Teaching basic life support to nurses. Eur J Anaesthesiol 2006;23:327-31. [3] 2005 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 3: defibrillation. Resuscitation 2005;67: 203-11. [4] Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 4: the automated external defibrillator: key link in the chain of survival. The American Heart Association in Collaboration with the International Liaison Committee on Resuscitation. Circulation 2000;102:60-76. [5] Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the “chain of survival” concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991;83:1832-47. [6] D-HLR med halvautomatisk defibrillator3:e ed. Göteborg: Stiftelsen för HLR, Svenska Cardiologföreningen; 2001. [7] S-HLR, HLR för sjukvårdspersonal. Instruktörsbok1:a ed. . Göteborg: Stiftelsen för HLR, Svenska rådet för hjärt-lungräddning; 2006. [8] Teaching adults resuscitation. Antwerpen, Belgium: European Resuscitation Council; 2007. [9] Beaman A, Barnes P, Klentz B, McQuirk B. Increasing helping rates through information dissemination: teaching pays. Pers Soc Psychol Bull 1978;4:406-11. [10] Polit DF, Hungler BP. Nursing research: principles and methods. Philaselphia: Lippincott Williams & Williams; 1999.
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Correspondence
Table 3 The rate of correct response and the Raw Agreement Measure on each question when presented to 2 different groups of 21 respondents before and after corrections of single questions in a questionnaire concerning knowledge in heart-lung resuscitation Question
1 2 3 4 5 6 7 8 9 10 11 12 13 14 Average a
Rate of correct response, first group (%)
Rate of correct response, second group (%)
Raw Agreement Measure, first group (%)
Raw Agreement Measure, second group (%)
No. of respondents answering “Don't know”
No. of respondents who didn't give any response
2:1
2:2
1:1
1:2
2:1
2:2
100 52 47 85 NA 66 76 42 NA 47 100 42 100 85 70.2
100 57 76 80 50 80 76 57 14 61 100 38 100 76 75.1
100 85 80 95 NA 100 84 78 NA 90 100 90 100 90 91.0
100 85 95 100 71 100 90 95 61 85 100 85 100 80 92.9
– – – 3 4 3 3 4 6 1 – 1 – –
– 1 – 3 5 3 2 4 5 – – 1 – –
– – – – – – 2 2 – – – – – 2
– – – – – – 2 2 – – – – – 2
– – – – 1 – – – 1 3 – – – 2
– – – – 1 – – – 2 – – – – 2
Note: The rate of correct response indicates correct response at both occasions (6-10 days in between) for the 2 groups of respondents. Raw Agreement Measure indicates the agreement in the response irrespective of right or wrong response. Don't know means that the respondents chose the response alternative “Don't know”. The response alternative “Don't know” was not available in the first version of the questionnaire. 1:1 indicates first version, first response; 1:2, first version, second response; 2:1, second version, first response; 2:2, second version, second response; NA, not available. a Not including questions 5 and 9.
[11] Masters JC, Hulsmeyer BS, Pike ME, Leichty K, Miller MT, Verst AL. Assessment of multiple-choice questions in selected test banks accompanying text books used in nursing education. J Nurs Educ 2001;40:25-32.
Should etomidate be used for rapid-sequence intubation induction in critically ill septic patients? Probably not To the Editor, Etomidate as an induction agent for critically ill patients was widely debated in the European intensive care and anesthesia literature in 2005 [1,2]. As Fengler describes, etomidate is well recognized to cause adrenal suppression in both elective surgical patients [3,4] and more profoundly in the critically ill. Adrenal suppression in this patient group is associated with increased mortality [5]. The use of steroid supplementation in severe sepsis and septic shock is still undecided, and CORTICUS has shown no benefit from the use of steroids in patients with or without evidence of adrenal axis suppression [6]. Etomidate use continues to be associated with a worse outcome and adrenal suppression [7-12]. Surely there can be no justification for using a drug
that is known to cause adrenal suppression, where this is associated with increased mortality and where other options exist. In sepsis, the volume of distribution of many drugs including induction agents is altered. Furthermore, in states of septic shock, blood is preferentially distributed to the vital organs, ultimately the brain and the heart. This will result in a greater concentration, than would be anticipated, of induction agent at its site of action. A reduced drug dose can therefore be administered. In severe sepsis and septic shock, cardiac output is also altered (increased or decreased), resulting in an altered circulation time. These factors in combination imply that a traditional approach to rapid sequence induction cannot be undertaken. In critically ill patients with sepsis, conventional induction agents result in significantly less cardiovascular instability if they are titrated slowly to effect rather than given on a dose per kilogram basis. When used in this way, significantly less drug is required. Cricoid pressure can still be applied throughout this process to prevent passive regurgitation of gastric contents. Both propofol (2,6-diisopropylphenol) and thiopentone sodium (sodium thiopental) can be used in this way. The concomitant use of liberal fluid resuscitation and, where necessary, vasopressors can prevent profound hypotension.