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In-hospital resuscitation—what should we be teaching?
Resuscitation 41 (1999) 179 – 183 www.elsevier.com/locate/resuscitation
In-hospital resuscitation—what should we be teaching? Vicki Leah a, Timothy John Coats b,* b
a Joyce Green Hospital, Dartford, Kent, UK St. Bartholomew’s and the Royal London School of Medicine and Dentistry, Queen Mary and Westfield College, London, UK
Received 5 December 1998; received in revised form 29 March 1999; accepted 1 April 1999
Abstract This paper examines the initial actions that should take place following the sudden collapse of a patient in a hospital. The current Basic Life Support guidelines are not designed for this situation, yet are commonly taught to hospital staff. An alternative algorithm for Hospital Resuscitation has been developed. Additional factors, such as the recognition of the sick patient and the importance of audit should be included in hospital resuscitation training. A tiered approach to resuscitation training within a hospital should be adopted and national standards developed. © 1999 Elsevier Science B.V. All rights reserved. Keywords: Cardiac Arrest; Cardiopulmonary resuscitation; Guidelines
1. Introduction There are at present no national guidelines or standards for NHS hospitals that specify in-house resuscitation facilities or training. Much attention has been directed to the formulation of standard guidelines for resuscitation and the structure of advanced resuscitation training. However, there has been little discussion in the medical literature of the most appropriate overall pattern of in-hospital resuscitation training [1,2]. As the number of Resuscitation Officers (ROs or RTOs) has increased over the past 10 years most hospitals now have a Resuscitation Service [3]. The content of resuscitation training for a hospital is decided by individual Resuscitation Officers, who are strongly influenced by the European Resuscitation Council Guidelines [4] on Basic [5] and Advanced [6] Life Support. The major part of a typical 2-h resuscitation training session for hospital staff is instruction in Basic Life Support (BLS). This type of training usually * Corresponding author. A&E Department, The Royal London Hospital, Whitechapel, London, E1 1BB, UK. Tel.: + 44-1713777728; fax: + 44-171-3777014. E-mail address: [email protected] (T.J. Coats)
forms the major part of the standard level of resuscitation training, with most staff undertaking regular (annual) updates. Current BLS guidelines are designed to enable lay bystanders to give initial CPR following sudden collapse in the community. They were not designed for in-hospital use and are therefore not an appropriate sequence of actions for a professional to take following the sudden collapse of a patient in a hospital ward. As the ‘Chain of Survival’ is different in hospital [7] the sequence of actions should also be different. Teaching in hospital that strictly follows pre-hospital BLS guidelines [8] is inappropriate and may in fact harm patients by increasing time to definitive intervention.
2. Initial actions in hospital Following a sudden collapse in hospital there are a number of priorities. If a patient is suddenly unresponsive any staff in the immediate vicinity should be called to assist. There will never be only one member of staff on a ward (or most other areas of a hospital) so it can be assumed that at
0300-9572/99/$ - see front matter © 1999 Elsevier Science B.V. All rights reserved. PII: S 0 3 0 0 - 9 5 7 2 ( 9 9 ) 0 0 0 3 8 - 6
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V. Leah, T.J. Coats / Resuscitation 41 (1999) 179–183
least two people are available to treat the patient. Advanced Life Support providers need to be alerted with a ‘cardiac arrest call’. Significant numbers of survivors of in-hospital cardiac arrest are only likely in patients with ventricular fibrillation, so the priority is early monitoring and defibrillation. It is ideal for the first responder to provide definitive treatment. With new technology, such as semi-automated defibrillators (AEDs), definitive treatment by ward staff (defibrillation) should be possible for all patients that are potential survivors (i.e. those in a shockable rhythm) [9]. If defibrillation is not indicated (or while monitoring is being established) ventilation with oxygen and chest compressions are required. In areas where patients are monitored (such as CCU, ITU or A&E) a different sequence of actions would be appropriate. Outside the clinical environment (for example the hospital grounds or corridors) layperson BLS protocols may be appropriate until equipment arrives.
3. Hospital resuscitation A suggested algorithm for the initial management of in-hospital cardiac arrest is shown in Fig.
1. When a member of staff finds a collapsed patient in a clinical area they should first shout for help then assess if the patient is responsive (shake and shout). There will always be one or more members of staff in the vicinity so simultaneous actions can be carried out. If the patient is unresponsive, while other members of staff are arriving the first person on the scene should check for a pulse. If a pulse can definitely be felt the Medical Emergency Team should be called, MOVE (Monitor, Oxygen, Venous access, ECG) should be performed and assessment/treatment of the ‘Sick Patient’ continued (beyond the scope of this article). If there is not a definite pulse the Cardiac Arrest Management Team should be called. If only two members of staff are present they should both leave the patient. As one member of staff is calling this Team another should fetch a monitor/defibrillator (usually as part of the ‘crash trolley’). The electrodes should be immediately applied to the patient and the rhythm analysed. Either manual or semi-automatic defibrillation (AED) should be carried out if required. AEDs should be immediately available and all qualified nurses should be trained in their use [10]. If defibrillation is not indicated or there is delay in access to a defibrillator (which should be criti-
Fig. 1. Algorithm for hospital resuscitation.
V. Leah, T.J. Coats / Resuscitation 41 (1999) 179–183
181
Fig. 2. Alternative algorithm for hospital resuscitation if no medical emergency team.
cally evaluated as part of the audit process) ventilation with oxygen should be started. This should be preferably with a pocket mask and oxygen (but a bag-valve-mask or laryngeal mask may be used according to local policy). It should be checked that the oxygen is both connected and turned on. Chest compressions should then be started at a ratio of 5:1. The ward staff should then start to look for the cause of the cardiac arrest. One person should be designated to give the handover to the cardiac arrest management team leader, preferably the nurse who knows most about the patient’s medical condition. If possible the patient’s notes should be located. The first line drug (adrenaline) should now be prepared along with the equipment for intubation. This will aid the cardiac arrest management team when it arrives. After the arrival of the cardiac arrest management team, ward staff should then be able continue to help by anticipating the needs of cardiac arrest team, which involves knowing the cardiac arrest treatment algorithms. If there is not a Medical Emergency Team system in place it may be appropriate to call the cardiac arrest management team for every patient unresponsive following a sudden collapse. This would modify the algorithm, as shown in Fig. 2.
Here assessment of the pulse would occur at the same time as calling the cardiac arrest management team. Even if the patient is not in cardiac arrest, sudden unresponsiveness requires the immediate attendance of a senior medical team. The concept of a specific cardiac arrest management team may be outdated, as by definition this team is called too late. The name and function of this team may require change in the future.
4. Differences from current BLS protocols. Checking for a safe environment may be important if a patient is found collapsed outside hospital, but it is irrelevant in a ward. Scenarios in which, for example, a patient is electrocuted on a ward are so fanciful that they can be safely ignored. Establishing a safe environment should therefore not be part of hospital resuscitation. In hospital when a patient suddenly collapses agonal respiration is common [11]. This may lead to a delay in the diagnosis of cardiac arrest if staff assume that the patient is ‘breathing’. This confusion may arise because, according to standard BLS protocols, a breathing patient is not in cardiac arrest. Clearing the airway and checking breathing should therefore not be part of hospital
182
V. Leah, T.J. Coats / Resuscitation 41 (1999) 179–183
resuscitation. After a sudden collapse in hospital a pulse should be checked immediately and the cardiac arrest management team called if a definite pulse cannot be felt. Airway manoeuvres would be performed later in the sequence of action as part of ‘Ventilation with oxygen’. As a pocket mask is such an inexpensive item of equipment one should be located in all clinical and non-clinical areas. No part of the hospital should be more than a short distance from a pocket mask. Mouth-to-mouth ventilation should therefore never be required, and so this should not be part of hospital resuscitation training. It must be emphasised that oxygen should be used whenever ventilation is performed, with oxygen readily available in wall mounted or portable form.
5. Additional training The algorithm presented here is simpler than standard BLS guidelines, but still conforms to the Universal ALS algorithm [12]. This simpler format will take less time to teach and so will allow instruction on other important in-hospital topics, such as the recognition of the high risk patient, initial actions for the sick patient and audit of cardiac arrest outcomes. There is good evidence that a group of patients can be identified who are at risk of cardiac arrest. Many patients who suffer in-hospital cardiac arrest are observed to have significant physiological abnormality before the acute event. These abnormalities are often not responded to by nursing or junior medical staff [13]. The recognition of the patient at risk of cardiac arrest is therefore an important part of hospital resuscitation training. This inevitably overlaps with the identification and initial treatment of the sick patient and the use of a Medical Emergency Team [14]. Nurses on general wards are the most important group to train as they will be in the best position to identify early deterioration in their patients. Initial actions on identification of the sick patient should also be taught in hospital resuscitation training. Staff should be taught to call for medical assistance (a medical emergency team is the ideal) and to ‘MOVE’ while waiting for help
to arrive. This consists of early Monitoring, Oxygen, Venous access and ECG. A discussion of the importance of audit should also be added. This is an important part of quality assurance in resuscitation [15], so hospital resuscitation training should emphasise the value of accurate note keeping and the completion of audit forms. This is an important component of clinical governance, and should be presented as a positive way in which staff can improve patient treatment, rather than as a punitive exercise to ‘check up’ on staff actions. 6. Tiered training There are a large number of different types and grades of staff within a NHS Hospital. It would not be appropriate to teach the same topics to all staff. A tiered approach is required that identifies the needs of different groups of staff. A parallel set of tiers is required for staff involved in the treatment and resuscitation of sick children. The most advanced tier is the senior nursing staff and junior doctors in acute areas who need hospital resuscitation training, as detailed in this paper, combined with a Resuscitation Council Advanced Life Support Course. The hospital resuscitation training should be revised every year, the ALS course every 3 years. Resuscitation Officers should be trained to this advanced tier. All other medical and nursing staff should undergo Hospital Resuscitation Training, including the recognition of the sick adult and initial actions for the sick adult, but would not need to undergo a formal Advanced Life Support Course. Re-training should be carried out every year. Paramedical staff, such as physiotherapists and operating department assistants should undergo hospital resuscitation training, with an annual update. These staff need less emphasis on the initial treatment of a sick patient, but more emphasis on when and how to call for help. Paramedical staff involved in the cardiac arrest team will need training to a higher tier. Ancillary staff (such as porters, clerical staff and cleaners) and hospital managers should undergo conventional Basic Life Support Training, such as that provided by the British Heart Foundation Heartstart scheme. This will enable
V. Leah, T.J. Coats / Resuscitation 41 (1999) 179–183
these staff to provide an initial response on the rare occasions when they witness a collapse in a non-clinical area of the hospital, and will also enable them to respond to an emergency at home or in the street. The current situation in which teaching is determined by individual Resuscitation Officers is unsatisfactory as individual idiosyncrasies and interests lead to large variations in the content of training. This is an area in which it would be appropriate for the NHS Training and Development structure to provide national recommendations.
7. Training in context Throughout all of the tiers of training there should be an emphasis on using the usual context in which people work. This involves the use of realistic scenarios, which means that the teacher must be familiar with the activity and routines within each clinical area. Training in context requires hospital resuscitation training to move out of the classroom and into clinical areas. For example a group of radiographers should be taught in the X-ray Department using the equipment that they have in the department. Important additional learning will take place, such as the location of emergency equipment, the importance of checking emergency equipment and how to handle particular special situations (for example cardiac arrest inside a scanner). Some disruption to clinical work is inevitable.
8. Conclusion Basic Life Support algorithms designed for layperson resuscitation are not appropriate for inhospital management of the collapsed patient, yet are widely taught to hospital staff. Hospital resuscitation training should reflect the reality of the clinical situation that presents when a patient suffers a cardiac arrest in a hospital, and should include the recognition of the sick patient, initial actions for the sick patient and the importance of audit. A tiered approach directs appropriate training to all members of staff, with training in context assisting the application of these skills to normal clinical situations. .
183
References [1] Sandoe E. Organization of resuscitation within the hospital. Am J Emerg Med 1984;2(3):270 – 2. [2] Cummins RO, Sanders A, Mancini E, et al. In-hospital resuscitation: a statement for healthcare professionals from the American Heart Association Emergency Cardiac Care Committee and the Advanced Cardiac Life Support, Basic Life Support, Pediatric Resuscitation, and Program Administration Subcommittees. Circulation 1997;95(8):2211– 2. [3] Leah V, Coats T. Resuscitation Officers: time for standardisation? (Editorial). Hosp Med 1998;59(3):184. [4] Nolan J, Gwinnutt C. 1998 European guidelines on resuscitation. Simplifications should make them easier to teach and implement (editorial). Br Med J 1998;316(7148):1844– 5. [5] Handley AJ, Bahr J, Baskett P, et al. The 1998 European Resuscitation Council guidelines for adult single rescuer basic life support: a statement from the Working Group on Basic Life Support, and approved by the executive committee. Resuscitation 1998;37(2):67–80. [6] Robertson CE. Advanced life support guidelines. European Resuscitation Council. Br J Anaesth 1997;79(2):172– 7. [7] Kaye W, Mancini M. Improving outcome form cardiac arrest in the hospital with a reorganized and strengthened chain of survival: an American view. Resuscitation 1996;31:181 – 6. [8] Liddle R, Carr L. Resuscitation Training Officer Resource Pack. http://www.moreton.com/resus, 1998. [9] Kaye W, Mancini ME, Giuliano KK, et al. Strengthening the in-hospital chain of survival with rapid defibrillation by first responders using automated external defibrillators: training and retention issues. Ann Emerg Med 1995;25(2):163– 8. [10] Kaye W, Mancini ME, Richards N. Organizing and implementing a hospital-wide first-responder automated external defibrillation program: strengthening the inhospital chain of survival. Resuscitation 1995;30(2):151– 6. [11] Clark JJ, Larsen MP, Culley LL, et al. Incidence of agonal respirations in sudden cardiac arrest. Ann Emerg Med 1992;21(12):1464– 7. [12] Kloek W, Cummins R, Chamberlain D, et al. The Universal ALS algorithm. An advisory statement by the Advanced Life Support Working Group of the International Liaison Committee on Resuscitation. Resuscitation 1997;34(2):109– 11. [13] Garrard C, Young D. Suboptimal care of patients before admission to intensive care (Editorial). Br Med J 1998;316:1841– 2. [14] Lee A, Bishop G, Hillman K, et al. The Medical Emergency Team. Anaesth Intensive Care 1995;23(2):183– 6. [15] Cummins RO, Chamberlain D, Hazinski MF, et al. Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the inhospital ‘Utstein style’. American Heart Association. Ann Emerg Med 1997;29(5):650– 79.
In-hospital resuscitation—what should we be teaching? Vicki Leah a, Timothy John Coats b,* b
a Joyce Green Hospital, Dartford, Kent, UK St. Bartholomew’s and the Royal London School of Medicine and Dentistry, Queen Mary and Westfield College, London, UK
Received 5 December 1998; received in revised form 29 March 1999; accepted 1 April 1999
Abstract This paper examines the initial actions that should take place following the sudden collapse of a patient in a hospital. The current Basic Life Support guidelines are not designed for this situation, yet are commonly taught to hospital staff. An alternative algorithm for Hospital Resuscitation has been developed. Additional factors, such as the recognition of the sick patient and the importance of audit should be included in hospital resuscitation training. A tiered approach to resuscitation training within a hospital should be adopted and national standards developed. © 1999 Elsevier Science B.V. All rights reserved. Keywords: Cardiac Arrest; Cardiopulmonary resuscitation; Guidelines
1. Introduction There are at present no national guidelines or standards for NHS hospitals that specify in-house resuscitation facilities or training. Much attention has been directed to the formulation of standard guidelines for resuscitation and the structure of advanced resuscitation training. However, there has been little discussion in the medical literature of the most appropriate overall pattern of in-hospital resuscitation training [1,2]. As the number of Resuscitation Officers (ROs or RTOs) has increased over the past 10 years most hospitals now have a Resuscitation Service [3]. The content of resuscitation training for a hospital is decided by individual Resuscitation Officers, who are strongly influenced by the European Resuscitation Council Guidelines [4] on Basic [5] and Advanced [6] Life Support. The major part of a typical 2-h resuscitation training session for hospital staff is instruction in Basic Life Support (BLS). This type of training usually * Corresponding author. A&E Department, The Royal London Hospital, Whitechapel, London, E1 1BB, UK. Tel.: + 44-1713777728; fax: + 44-171-3777014. E-mail address: [email protected] (T.J. Coats)
forms the major part of the standard level of resuscitation training, with most staff undertaking regular (annual) updates. Current BLS guidelines are designed to enable lay bystanders to give initial CPR following sudden collapse in the community. They were not designed for in-hospital use and are therefore not an appropriate sequence of actions for a professional to take following the sudden collapse of a patient in a hospital ward. As the ‘Chain of Survival’ is different in hospital [7] the sequence of actions should also be different. Teaching in hospital that strictly follows pre-hospital BLS guidelines [8] is inappropriate and may in fact harm patients by increasing time to definitive intervention.
2. Initial actions in hospital Following a sudden collapse in hospital there are a number of priorities. If a patient is suddenly unresponsive any staff in the immediate vicinity should be called to assist. There will never be only one member of staff on a ward (or most other areas of a hospital) so it can be assumed that at
0300-9572/99/$ - see front matter © 1999 Elsevier Science B.V. All rights reserved. PII: S 0 3 0 0 - 9 5 7 2 ( 9 9 ) 0 0 0 3 8 - 6
180
V. Leah, T.J. Coats / Resuscitation 41 (1999) 179–183
least two people are available to treat the patient. Advanced Life Support providers need to be alerted with a ‘cardiac arrest call’. Significant numbers of survivors of in-hospital cardiac arrest are only likely in patients with ventricular fibrillation, so the priority is early monitoring and defibrillation. It is ideal for the first responder to provide definitive treatment. With new technology, such as semi-automated defibrillators (AEDs), definitive treatment by ward staff (defibrillation) should be possible for all patients that are potential survivors (i.e. those in a shockable rhythm) [9]. If defibrillation is not indicated (or while monitoring is being established) ventilation with oxygen and chest compressions are required. In areas where patients are monitored (such as CCU, ITU or A&E) a different sequence of actions would be appropriate. Outside the clinical environment (for example the hospital grounds or corridors) layperson BLS protocols may be appropriate until equipment arrives.
3. Hospital resuscitation A suggested algorithm for the initial management of in-hospital cardiac arrest is shown in Fig.
1. When a member of staff finds a collapsed patient in a clinical area they should first shout for help then assess if the patient is responsive (shake and shout). There will always be one or more members of staff in the vicinity so simultaneous actions can be carried out. If the patient is unresponsive, while other members of staff are arriving the first person on the scene should check for a pulse. If a pulse can definitely be felt the Medical Emergency Team should be called, MOVE (Monitor, Oxygen, Venous access, ECG) should be performed and assessment/treatment of the ‘Sick Patient’ continued (beyond the scope of this article). If there is not a definite pulse the Cardiac Arrest Management Team should be called. If only two members of staff are present they should both leave the patient. As one member of staff is calling this Team another should fetch a monitor/defibrillator (usually as part of the ‘crash trolley’). The electrodes should be immediately applied to the patient and the rhythm analysed. Either manual or semi-automatic defibrillation (AED) should be carried out if required. AEDs should be immediately available and all qualified nurses should be trained in their use [10]. If defibrillation is not indicated or there is delay in access to a defibrillator (which should be criti-
Fig. 1. Algorithm for hospital resuscitation.
V. Leah, T.J. Coats / Resuscitation 41 (1999) 179–183
181
Fig. 2. Alternative algorithm for hospital resuscitation if no medical emergency team.
cally evaluated as part of the audit process) ventilation with oxygen should be started. This should be preferably with a pocket mask and oxygen (but a bag-valve-mask or laryngeal mask may be used according to local policy). It should be checked that the oxygen is both connected and turned on. Chest compressions should then be started at a ratio of 5:1. The ward staff should then start to look for the cause of the cardiac arrest. One person should be designated to give the handover to the cardiac arrest management team leader, preferably the nurse who knows most about the patient’s medical condition. If possible the patient’s notes should be located. The first line drug (adrenaline) should now be prepared along with the equipment for intubation. This will aid the cardiac arrest management team when it arrives. After the arrival of the cardiac arrest management team, ward staff should then be able continue to help by anticipating the needs of cardiac arrest team, which involves knowing the cardiac arrest treatment algorithms. If there is not a Medical Emergency Team system in place it may be appropriate to call the cardiac arrest management team for every patient unresponsive following a sudden collapse. This would modify the algorithm, as shown in Fig. 2.
Here assessment of the pulse would occur at the same time as calling the cardiac arrest management team. Even if the patient is not in cardiac arrest, sudden unresponsiveness requires the immediate attendance of a senior medical team. The concept of a specific cardiac arrest management team may be outdated, as by definition this team is called too late. The name and function of this team may require change in the future.
4. Differences from current BLS protocols. Checking for a safe environment may be important if a patient is found collapsed outside hospital, but it is irrelevant in a ward. Scenarios in which, for example, a patient is electrocuted on a ward are so fanciful that they can be safely ignored. Establishing a safe environment should therefore not be part of hospital resuscitation. In hospital when a patient suddenly collapses agonal respiration is common [11]. This may lead to a delay in the diagnosis of cardiac arrest if staff assume that the patient is ‘breathing’. This confusion may arise because, according to standard BLS protocols, a breathing patient is not in cardiac arrest. Clearing the airway and checking breathing should therefore not be part of hospital
182
V. Leah, T.J. Coats / Resuscitation 41 (1999) 179–183
resuscitation. After a sudden collapse in hospital a pulse should be checked immediately and the cardiac arrest management team called if a definite pulse cannot be felt. Airway manoeuvres would be performed later in the sequence of action as part of ‘Ventilation with oxygen’. As a pocket mask is such an inexpensive item of equipment one should be located in all clinical and non-clinical areas. No part of the hospital should be more than a short distance from a pocket mask. Mouth-to-mouth ventilation should therefore never be required, and so this should not be part of hospital resuscitation training. It must be emphasised that oxygen should be used whenever ventilation is performed, with oxygen readily available in wall mounted or portable form.
5. Additional training The algorithm presented here is simpler than standard BLS guidelines, but still conforms to the Universal ALS algorithm [12]. This simpler format will take less time to teach and so will allow instruction on other important in-hospital topics, such as the recognition of the high risk patient, initial actions for the sick patient and audit of cardiac arrest outcomes. There is good evidence that a group of patients can be identified who are at risk of cardiac arrest. Many patients who suffer in-hospital cardiac arrest are observed to have significant physiological abnormality before the acute event. These abnormalities are often not responded to by nursing or junior medical staff [13]. The recognition of the patient at risk of cardiac arrest is therefore an important part of hospital resuscitation training. This inevitably overlaps with the identification and initial treatment of the sick patient and the use of a Medical Emergency Team [14]. Nurses on general wards are the most important group to train as they will be in the best position to identify early deterioration in their patients. Initial actions on identification of the sick patient should also be taught in hospital resuscitation training. Staff should be taught to call for medical assistance (a medical emergency team is the ideal) and to ‘MOVE’ while waiting for help
to arrive. This consists of early Monitoring, Oxygen, Venous access and ECG. A discussion of the importance of audit should also be added. This is an important part of quality assurance in resuscitation [15], so hospital resuscitation training should emphasise the value of accurate note keeping and the completion of audit forms. This is an important component of clinical governance, and should be presented as a positive way in which staff can improve patient treatment, rather than as a punitive exercise to ‘check up’ on staff actions. 6. Tiered training There are a large number of different types and grades of staff within a NHS Hospital. It would not be appropriate to teach the same topics to all staff. A tiered approach is required that identifies the needs of different groups of staff. A parallel set of tiers is required for staff involved in the treatment and resuscitation of sick children. The most advanced tier is the senior nursing staff and junior doctors in acute areas who need hospital resuscitation training, as detailed in this paper, combined with a Resuscitation Council Advanced Life Support Course. The hospital resuscitation training should be revised every year, the ALS course every 3 years. Resuscitation Officers should be trained to this advanced tier. All other medical and nursing staff should undergo Hospital Resuscitation Training, including the recognition of the sick adult and initial actions for the sick adult, but would not need to undergo a formal Advanced Life Support Course. Re-training should be carried out every year. Paramedical staff, such as physiotherapists and operating department assistants should undergo hospital resuscitation training, with an annual update. These staff need less emphasis on the initial treatment of a sick patient, but more emphasis on when and how to call for help. Paramedical staff involved in the cardiac arrest team will need training to a higher tier. Ancillary staff (such as porters, clerical staff and cleaners) and hospital managers should undergo conventional Basic Life Support Training, such as that provided by the British Heart Foundation Heartstart scheme. This will enable
V. Leah, T.J. Coats / Resuscitation 41 (1999) 179–183
these staff to provide an initial response on the rare occasions when they witness a collapse in a non-clinical area of the hospital, and will also enable them to respond to an emergency at home or in the street. The current situation in which teaching is determined by individual Resuscitation Officers is unsatisfactory as individual idiosyncrasies and interests lead to large variations in the content of training. This is an area in which it would be appropriate for the NHS Training and Development structure to provide national recommendations.
7. Training in context Throughout all of the tiers of training there should be an emphasis on using the usual context in which people work. This involves the use of realistic scenarios, which means that the teacher must be familiar with the activity and routines within each clinical area. Training in context requires hospital resuscitation training to move out of the classroom and into clinical areas. For example a group of radiographers should be taught in the X-ray Department using the equipment that they have in the department. Important additional learning will take place, such as the location of emergency equipment, the importance of checking emergency equipment and how to handle particular special situations (for example cardiac arrest inside a scanner). Some disruption to clinical work is inevitable.
8. Conclusion Basic Life Support algorithms designed for layperson resuscitation are not appropriate for inhospital management of the collapsed patient, yet are widely taught to hospital staff. Hospital resuscitation training should reflect the reality of the clinical situation that presents when a patient suffers a cardiac arrest in a hospital, and should include the recognition of the sick patient, initial actions for the sick patient and the importance of audit. A tiered approach directs appropriate training to all members of staff, with training in context assisting the application of these skills to normal clinical situations. .
183
References [1] Sandoe E. Organization of resuscitation within the hospital. Am J Emerg Med 1984;2(3):270 – 2. [2] Cummins RO, Sanders A, Mancini E, et al. In-hospital resuscitation: a statement for healthcare professionals from the American Heart Association Emergency Cardiac Care Committee and the Advanced Cardiac Life Support, Basic Life Support, Pediatric Resuscitation, and Program Administration Subcommittees. Circulation 1997;95(8):2211– 2. [3] Leah V, Coats T. Resuscitation Officers: time for standardisation? (Editorial). Hosp Med 1998;59(3):184. [4] Nolan J, Gwinnutt C. 1998 European guidelines on resuscitation. Simplifications should make them easier to teach and implement (editorial). Br Med J 1998;316(7148):1844– 5. [5] Handley AJ, Bahr J, Baskett P, et al. The 1998 European Resuscitation Council guidelines for adult single rescuer basic life support: a statement from the Working Group on Basic Life Support, and approved by the executive committee. Resuscitation 1998;37(2):67–80. [6] Robertson CE. Advanced life support guidelines. European Resuscitation Council. Br J Anaesth 1997;79(2):172– 7. [7] Kaye W, Mancini M. Improving outcome form cardiac arrest in the hospital with a reorganized and strengthened chain of survival: an American view. Resuscitation 1996;31:181 – 6. [8] Liddle R, Carr L. Resuscitation Training Officer Resource Pack. http://www.moreton.com/resus, 1998. [9] Kaye W, Mancini ME, Giuliano KK, et al. Strengthening the in-hospital chain of survival with rapid defibrillation by first responders using automated external defibrillators: training and retention issues. Ann Emerg Med 1995;25(2):163– 8. [10] Kaye W, Mancini ME, Richards N. Organizing and implementing a hospital-wide first-responder automated external defibrillation program: strengthening the inhospital chain of survival. Resuscitation 1995;30(2):151– 6. [11] Clark JJ, Larsen MP, Culley LL, et al. Incidence of agonal respirations in sudden cardiac arrest. Ann Emerg Med 1992;21(12):1464– 7. [12] Kloek W, Cummins R, Chamberlain D, et al. The Universal ALS algorithm. An advisory statement by the Advanced Life Support Working Group of the International Liaison Committee on Resuscitation. Resuscitation 1997;34(2):109– 11. [13] Garrard C, Young D. Suboptimal care of patients before admission to intensive care (Editorial). Br Med J 1998;316:1841– 2. [14] Lee A, Bishop G, Hillman K, et al. The Medical Emergency Team. Anaesth Intensive Care 1995;23(2):183– 6. [15] Cummins RO, Chamberlain D, Hazinski MF, et al. Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the inhospital ‘Utstein style’. American Heart Association. Ann Emerg Med 1997;29(5):650– 79.