Potential to enhance telephone cardiopulmonary resuscitation with improved instructions - findings from a simulation-based manikin study with lay rescuers.

BACKGROUND: Telephone-Cardiopulmonary Resuscitation (T-CPR) significantly increases rate of bystander resuscitation and improves patient outcomes after out-of-hospital cardiac arrest (OHCA). Nevertheless, securing correct execution of instructions remains a difficulty. ERC Guidelines 2021 recommend standardised instructions with continuous evaluation. Yet, there are no explicit recommendations on a standardised wording of T-CPR in the German language. We investigated, whether a modified wording regarding check for breathing in a German T-CPR protocol improved performance of T-CPR. METHODS: A simulation study with 48 OHCA scenarios was conducted. In a non-randomised trial study lay rescuers were instructed using the real-life-CPR protocol of the regional dispatch centre and as the intervention a modified T-CPR protocol, including specific check for breathing (head tilt-chin lift instructions). Resuscitation parameters were assessed with a manikin and video recordings. RESULTS: Check for breathing was performed by 64.3% (n = 14) of the lay rescuers with original wording and by 92.6% (n = 27) in the group with modified wording (p = 0.035). In the original wording group the head tilt-chin manoeuvre was executed by 0.0% of the lay rescuers compared to 70.3% in the group with modified wording (p < 0.001). The average duration of check for breathing was 1 ± 1 s in the original wording group and 4 ± 2 s in the group with modified wording (p < 0.001). Other instructions (e.g. check for consciousness and removal of clothing) were well performed and did not differ significantly between groups. Quality of chest compression did not differ significantly between groups, with the exception of mean chest compression depth, which was slightly deeper in the modified wording group. CONCLUSION: Correct check for breathing seems to be a problem for lay rescuers, which can be decreased by describing the assessment in more detail. Hence, T-CPR protocols should provide standardised explicit instructions on how to perform airway assessment. Each protocol should be evaluated for practicability.

Digital transition in rural emergency medicine: Impact of job satisfaction and workload on communication and technology acceptance.

BACKGROUND: Tele-emergency physicians (TEPs) take an increasingly important role in the need-oriented provision of emergency patient care. To improve emergency medicine in rural areas, we set up the project 'Rural|Rescue', which uses TEPs to restructure professional rescue services using information and communication technologies (ICTs) in order to reduce the therapy-free interval. Successful implementation of ICTs relies on user acceptance and knowledge sharing behavior. METHOD: We conducted a factorial design with active knowledge transfer and technology acceptance as a function of work satisfaction (high vs. low), workload (high vs. low) and point in time (prior to vs. after digitalization). Data were collected via machine readable questionnaires issued to 755 persons (411 pre, 344 post), of which 304 or 40.3% of these persons responded (194 pre, 115 post). RESULTS: Technology acceptance was higher after the implementation of TEP for nurses but not for other professions, and it was higher when the workload was high. Regarding active communication and knowledge sharing, employees with low work satisfaction are more likely to share their digital knowledge as compared to employees with high work satisfaction. This is an effect of previous knowledge concerning digitalization: After implementing the new technology, work satisfaction increased for the more experienced employees, but not for the less experienced ones. CONCLUSION: Our research illustrates that employees' workload has an impact on the intention of using digital applications. The higher the workload, the more people are willing to use TEPs. Regarding active knowledge sharing, we see that employees with low work satisfaction are more likely to share their digital knowledge compared to employees with high work satisfaction. This might be attributed to the Dunning-Kruger effect. Highly knowledgeable employees initially feel uncertain about the change, which translates into temporarily lower work satisfaction. They feel the urge to fill even small knowledge gaps, which in return leads to higher work satisfaction. Those responsible need to acknowledge that digital change affects their employees' workflow and work satisfaction. During such times, employees need time and support to gather information and knowledge in order to cope with digitally changed tasks.

[Is a tele-emergency physician system a sensible addition in rural German regions?-An analysis from a medical and economic perspective]. / Ist das Telenotarzt-System eine sinnvolle Ergänzung im ländlichen Raum? ­ Eine Analyse aus medizinischer und ökonomischer Perspektive.

BACKGROUND AND OBJECTIVES: In 2017, a tele-emergency-physician system was implemented in the county of Vorpommern-Greifswald (Germany) to optimise the prehospital emergency medical service and to counteract current challenges. It was evaluated from a medical and economic perspective whether a tele-emergency physician system is a useful addition to the existing prehospital emergency system, especially in rural regions. MATERIALS AND METHODS: Approximately 250,000 emergency medical service data from the years 2015 to 2020 (before and after the implementation of the telemedical system) were analysed in a pre-post comparison. A total of 3611 tele-emergency physician cases were analysed regarding medical indication and time-related factors. Additionally, total costs of the tele-emergency physician system as well as a cost analysis regarding prehospital and hospital medical costs of selected diseases were performed. RESULTS: The tele-emergency physician treated patients of all age groups with a wide spectrum of diseases. Of the cases, 48.2% were moderate to severe but not life-threatening disorders. Patients as well as emergency medical service personnel embraced the new system. According to the data, ambulances that were equipped with the telemedical system had the number of missions requiring an emergency physician on scene reduced significantly by 20%. The yearly costs of this telemedical system amount to €1.7 million. CONCLUSIONS: The tele-emergency physician system proved to be a telemedical innovation that is medically advisable, functional and cost-efficient. Therefore, the tele-emergency physician system continued to operate after the end of the research project and is ready to be implemented across Germany.

[Emergency medical service, medical on-call service, or emergency department : Germans unsure whom to contact in acute medical events]. / Rettungsdienst, kassenärztlicher Notdienst oder Notaufnahme : Es gelingt der Bevölkerung nur unzureichend, die richtige Ressource für medizinische Akutfälle zu wählen.

BACKGROUND: In medical events, patients have to independently decide whom to contact: emergency medical services, medical on-call service or emergency department. OBJECTIVES: Are Germans able to assess the urgency of medical events and choose the correct resource? MATERIALS AND METHODS: In 2018 a nationwide anonymous telephone survey was done in Gabler-Haeder design. In all, 708 interviewees were presented with six medical scenarios. Participants were asked to rate urgency and to assess whether medical help was necessary within minutes to hours. Telephone numbers of emergency medical services and medical on-call service were inquired. RESULTS: Urgency of different scenarios was often misjudged: in cases with high, medium, and low urgency the misjudgement rate were 20, 50, and 27%, respectively. If medical help was rated as necessary, some participants chose the wrong service: 25% would not call an ambulance in stroke or myocardial infarction. In cases with medium urgency, more respondents chose to consult an emergency department (38%) than to call medical on-call service (46%). CONCLUSIONS: Knowledge regarding different options for treatment of medical events and competence to assess urgency seem to be too low. Beside efforts to increase health literacy, one solution might be to introduce a joint telephone number for emergency medical services and medical on-call service with a uniform assessment tool and appropriate allocation.

One out of three bystanders of out-of-hospital cardiac arrests shows signs of pathological psychological processing weeks after the incident - results from structured telephone interviews.

BACKGROUND: Witnessing an out-of-hospital cardiac arrest (OHCA) is a traumatic experience. This study analyses bystanders` psychological processing of OHCA. We examined the potential impact of bystanders performing resuscitation and the influence of the relationship between bystander and patient (stranger vs. family/friend of the patient) on the psychological processing. METHODS: A telephone interview survey with bystanders, who witnessed an OHCA of an adult patient was performed weeks after the event between December 2014 and April 2016. The semi-standardized questionnaire contained a question regarding the paramount emotion at the time of the interview. In a post-hoc analysis statements given in response were rated by independent researchers into the categories "signs of pathological psychological processing", "physiological psychological processing" and "no signs of psychological distress due to the OHCA". RESULTS: In this analysis 89 telephone interviews were included. In 27 cases (30.3%) signs of pathological psychological processing could be detected. Bystanders performing resuscitation had a higher rate of "no signs of psychological distress after witnessing OHCA" compared to those not resuscitating (54.7% vs. 26.7%, p < 0.05; relative risk 2.01; 95%CI 1.08, 3.89). No statistical significant differences in the psychological processing could be shown for gender, age, relationship to the patient, current employment in the health sector, location of cardiac arrest or number of additional bystanders. CONCLUSIONS: One out of three bystanders of OHCA suffers signs of pathological psychological processing. This was independent of bystander´s age, gender and relationship to the patient. Performing resuscitation seems to help coping with witnessing OHCA.

Smartphone apps to support laypersons in bystander CPR are of ambivalent benefit: a controlled trial using medical simulation.

BACKGROUND: Bystander-initiated resuscitation is essential for surviving out-of-hospital cardiac arrest. Smartphone apps can provide real-time guidance for medical laypersons in these situations. Are these apps a beneficial addition to traditional resuscitation training? METHODS: In this controlled trial, we assessed the impact of app use on the quality of resuscitation (hands-off time, assessment of the patient's condition, quality of chest compression, body and arm positioning). Pupils who have previously undergone a standardised resuscitation training, encountered a simulated cardiac arrest either (i) without an app (control group); (ii) with facultative app usage; or (iii) with mandatory app usage. Measurements were compared using generalised linear regression. RESULTS: 200 pupils attended this study with 74 pupils in control group, 65 in facultative group and 61 in mandatory group. Participants who had to use the app significantly delayed the check for breathing, call for help, and first compression, leading to longer total hands-off time. Hands-off time during chest compression did not differ significantly. The percentage of correct compression rate and correct compression depth was significantly higher when app use was mandatory. Assessment of the patient's condition, and body and arm positioning did not differ. CONCLUSIONS: Smartphone apps offering real-time guidance in resuscitation can improve the quality of chest compression but may also delay the start of resuscitation. Provided that the app gives easy-to-implement, guideline-compliant instructions and that the user is familiar with its operation, we recommend smartphone-guidance as an additional tool to hands-on CPR-training to increase the prevalence and quality of bystander-initiated CPR.

Telemedical emergency services: central or decentral coordination?

BACKGROUND AND OBJECTIVE: Teleemergency doctors support ambulance cars at the emergency site by means of telemedicine. Currently, each district has its own teleemergency doctor office (decentralized solution). This paper analyses the advantages and disadvantages of a centralized solution where several teleemergency doctors work in parallel in one office to support the ambulances in more districts. METHODS: The service of incoming calls from ambulances to the teleemergency doctor office can be modelled as a queuing system. Based on the data of the district of Vorpommern-Greifswald in the Northeast of Germany, we assume that arrivals and services are Markov chains. The model has parallel channels proportionate to the number of teleemergency doctors working simultaneously and the number of calls which one doctor can handle in parallel. We develop a cost function with variable, fixed and step-fixed costs. RESULTS: For the district of Greifswald, the likelihood that an incoming call has to be put on hold because the teleemergency doctor is already fully occupied is negligible. Centralization of several districts with a higher number of ambulances in one teleemergency doctor office will increase the likelihood of overburdening and require more doctors working simultaneously. The cost of the teleemergency doctor office per ambulance serviced strongly declines with the number of districts cooperating. DISCUSSION: The calculations indicate that centralization is feasible and cost-effective. Other advantages (e.g. improved quality, higher flexibility) and disadvantages (lack of knowledge of the location and infrastructure) of centralization are discussed. CONCLUSIONS: We recommend centralization of telemedical emergency services. However, the number of districts cooperating in one teleemergency doctor office should not be too high and the distance between the ambulance station and the telemedical station should not be too large.

Smartphone-based dispatch of community first responders to out-of-hospital cardiac arrest - statements from an international consensus conference.

BACKGROUND: Over the past decade Smartphone-based activation (SBA) of Community First Responders (CFR) to out-of-hospital cardiac arrests (OHCA) has gained much attention and popularity throughout Europe. Various programmes have been established, and interestingly there are considerable differences in technology, responder spectrum and the degree of integration into the prehospital emergency services. It is unclear whether these dissimilarities affect outcome. This paper reviews the current state in five European countries, reveals similarities and controversies, and presents consensus statements generated in an international conference with the intention to support public decision making on future strategies for SBA of CFR. METHODS: In a consensus conference a three-step approach was used: (i) presentation of current research from five European countries; (ii) workshops discussing evidence amongst the audience to generate consensus statements; (iii) anonymous real-time voting applying the modified RAND-UCLA Appropriateness method to adopt or reject the statements. The consensus panel aimed to represent all stakeholders involved in this topic. RESULTS: While 21 of 25 generated statements gained approval, consensus was only found for 5 of them. One statement was rejected but without consensus. Members of the consensus conference confirmed that CFR save lives. They further acknowledged the crucial role of emergency medical control centres and called for nationwide strategies. CONCLUSIONS: Members of the consensus conference acknowledged that smartphone-based activation of CFR to OHCA saves lives. The statements generated by the consensus conference may assist the public, healthcare services and governments to utilise these systems to their full potential, and direct the research community towards fields that still need to be addressed.

Correction: Real-time feedback improves chest compression quality in out-of-hospital cardiac arrest: A prospective cohort study.

[This corrects the article DOI: 10.1371/journal.pone.0229431.].

Evaluation of a Rural Emergency Medical Service Project in Germany: Protocol for a Multimethod and Multiperspective Longitudinal Analysis.

BACKGROUND: German emergency medical services are a 2-tiered system with paramedic-staffed ambulances as the primary response, supported by prehospital emergency doctors for life-threatening conditions. As in all European health care systems, German medical practitioners are in short supply, whereas the demand for timely emergency medical care is constantly growing. In rural areas, this has led to critical delays in the provision of emergency medical care. In particular, in cases of cardiac arrest, time is of the essence because, with each passing minute, the chance of survival with good neurological outcome decreases. OBJECTIVE: The project has 4 main objectives: (1) reduce the therapy-free interval through widespread reinforcement of resuscitation skills and motivating the public to provide help (ie, bystander cardiopulmonary resuscitation), (2) provide faster professional first aid in addition to rescue services through alerting trained first aiders by mobile phone, (3) make more emergency physicians available more quickly through introducing the tele-emergency physician system, and (4) enhance emergency care through improving the cooperation between statutory health insurance on-call medical services (German: Kassenärztlicher Bereitschaftsdienst) and emergency medical services. METHODS: We will evaluate project implementation in a tripartite prospective and intervention study. First, in medical evaluation, we will assess the influences of various project measures on quality of care using multiple methods. Second, the economic evaluation will mainly focus on the valuation of inputs and outcomes of the different measures while considering various relevant indicators. Third, as part of the work and organizational analysis, we will assess important work- and occupational-related parameters, as well as network and regional indexes. RESULTS: We started the project in 2017 and will complete enrollment in 2020. We finished the preanalysis phase in September 2018. CONCLUSIONS: Overall, implementation of the project will entail realigning emergency medicine in rural areas and enhancing the quality of medical emergency care in the long term. We expect the project to lead to a measurable increase in medical laypersons' individual motivation to provide resuscitation, to strengthen resuscitation skills, and to result in medical laypersons providing first aid much more frequently. Furthermore, we intend the project to decrease the therapy-free interval in cases of cardiac arrest by dispatching first aiders via mobile phones. Previous projects in urban regions have shown that the tele-emergency physician system can provide a higher availability and quality of emergency call-outs in regular health care. We expect a closer interrelation of emergency practices of statutory health insurance physicians with the rescue service to lead to better coordination of rescue and on-call services. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/14358.

Real-time feedback improves chest compression quality in out-of-hospital cardiac arrest: A prospective cohort study.

BACKGROUND: Current guidelines underline the importance of high-quality chest compression during cardiopulmonary resuscitation (CPR), to improve outcomes. Contrary to this many studies show that chest compression is often carried out poorly in clinical practice, and long interruptions in compression are observed. This prospective cohort study aimed to analyse whether chest compression quality changes when a real-time feedback system is used to provide simultaneous audiovisual feedback on chest compression quality. For this purpose, pauses in compression, compression frequency and compression depth were compared. METHODS: The study included 292 out-of-hospital cardiac arrests in three consecutive study groups: first group, conventional resuscitation (no-sensor CPR); second group, using a feedback sensor to collect compression depth data without real-time feedback (sensor-only CPR); and third group, with real-time feedback on compression quality (sensor-feedback CPR). Pauses and frequency were analysed using compression artefacts on electrocardiography, and compression depth was measured using the feedback sensor. With this data, various parameters were determined in order to be able to compare the chest compression quality between the three consecutive groups. RESULTS: The compression fraction increased with sensor-only CPR (group 2) in comparison with no-sensor CPR (group 1) (80.1% vs. 87.49%; P < 0.001), but there were no further differences belonging compression fraction after activation of sensor-feedback CPR (group 3) (P = 1.00). Compression frequency declined over the three study groups, reaching the guideline recommendations (127.81 comp/min vs. 122.96 comp/min, P = 0.02 vs. 119.15 comp/min, P = 0.008) after activation of sensor-feedback CPR (group 3). Mean compression depth only changed minimally with sensor-feedback (52.49 mm vs. 54.66 mm; P = 0.16), but the fraction of compressions with sufficient depth (at least 5 cm) and compressions within the recommended 5-6 cm increased significantly with sensor-feedback CPR (56.90% vs. 71.03%; P = 0.003 and 28.74% vs. 43.97%; P < 0.001). CONCLUSIONS: The real-time feedback system improved chest compression quality regarding pauses in compression and compression frequency and facilitated compliance with the guideline recommendations. Compression depth did not change significantly after activation of the real-time feedback. Even the sole use of a CPR-feedback-sensor ("sensor-only CPR") improved performance regarding pauses in compression and compression frequency, a phenomenon known as the 'Hawthorne effect'. Based on this data real-time feedback systems can be expected to raise the quality level in some parts of chest compression quality. TRIAL REGISTRATION: International Clinical Trials Registry Platform of the World Health Organisation and German Register of Clinical Trials (DRKS00009903), Registered 09 February 2016 (retrospectively registered).

Combination of problem-based learning with high-fidelity simulation in CPR training improves short and long-term CPR skills: a randomised single blinded trial.

BACKGROUND: Performance of sufficient cardiopulmonary resuscitation (CPR) by medical personnel is critical to improve outcomes during cardiac arrest. It has however been shown that even health care professionals possess a lack of knowledge and skills in CPR performance. The optimal method for teaching CPR remains unclear, and data that compares traditional CPR instructional methods with newer modalities of CPR instruction are needed. We therefore conducted a single blinded, randomised study involving medical students in order to evaluate the short- and long-term effects of a classical CPR education compared with a bilateral approach to CPR training, consisting of problem-based learning (PBL) plus high fidelity simulation. METHODS: One hundred twelve medical students were randomized during a curricular anaesthesiology course to a control (n = 54) and an intervention (n = 58) group. All participants were blinded to group assignment and partook in a 30-min-lecture on CPR basics. Subsequently, the control group participated in a 90-min tutor-guided CPR hands-on-training. The intervention group took part in a 45-min theoretical PBL module followed by 45 min of high fidelity simulated CPR training. The rate of participants recognizing clinical cardiac arrest followed by sufficiently performed CPR was the primary outcome parameter of this study. CPR performance was evaluated after the intervention. In addition, a follow-up evaluation was conducted after 6 months. RESULTS: 51.9% of the intervention group met the criteria of sufficiently performed CPR as compared to only 12.5% in the control group on the day of the intervention (p = 0.007). Hands-off-time as a marker for CPR continuity was significantly less in the intervention group (24.0%) as compared to the control group (28.3%, p = 0.007, Hedges' g = 1.55). At the six-month follow-up, hands-off-time was still significantly lower in the intervention group (23.7% vs. control group: 31.0%, p = 0.006, Hedges' g = 1.88) but no significant difference in sufficiently performed CPR was detected (intervention group: 71.4% vs. control group: 54.5%, p = 0.55). CONCLUSION: PBL combined with high fidelity simulation training leads to a measurable short-term increase in initiating sufficient CPR by medical students immediately after training as compared to classical education. At six month post instruction, these differences remained only partially.

Medical Correctness and User Friendliness of Available Apps for Cardiopulmonary Resuscitation: Systematic Search Combined With Guideline Adherence and Usability Evaluation.

BACKGROUND: In case of a cardiac arrest, start of cardiopulmonary resuscitation by a bystander before the arrival of the emergency personnel increases the probability of survival. However, the steps of high-quality resuscitation are not known by every bystander or might be forgotten in this complex and time-critical situation. Mobile phone apps offering real-time step-by-step instructions might be a valuable source of information. OBJECTIVE: The aim of this study was to examine mobile phone apps offering real-time instructions in German or English in case of a cardiac arrest, to evaluate their adherence to current resuscitation guidelines, and to test their usability. METHODS: Our 3-step approach combines a systematic review of currently available apps guiding a medical layperson through a resuscitation situation, an adherence testing to medical guidelines, and a usability evaluation of the determined apps. The systematic review followed an adapted preferred reporting items for systematic reviews and meta-analyses flow diagram, the guideline adherence was tested by applying a conformity checklist, and the usability was evaluated by a group of mobile phone frequent users and emergency physicians with the system usability scale (SUS) tool. RESULTS: The structured search in Google Play Store and Apple App Store resulted in 3890 hits. After removing redundant ones, 2640 hits were checked for fulfilling the inclusion criteria. As a result, 34 apps meeting all inclusion criteria were identified. These included apps were analyzed to determine medical accuracy as defined by the European Resuscitation Council's guidelines. Only 5 out of 34 apps (15%, 5/34) fulfilled all criteria chosen to determine guideline adherence. All other apps provided no or wrong information on at least one relevant topic. The usability of 3 apps was evaluated by 10 mobile phone frequent users and 9 emergency physicians. Of these 3 apps, solely the app "HELP Notfall" (median=87.5) was ranked with an SUS score above the published average of 68. This app was rated significantly superior to "HAMBURG SCHOCKT" (median=55; asymptotic Wilcoxon test: z=-3.63, P<.01, n=19) and "Mein DRK" (median=32.5; asymptotic Wilcoxon test: z=-3.83, P<.01, n=19). CONCLUSIONS: Implementing a systematic quality control for health-related apps should be enforced to ensure that all products provide medically accurate content and sufficient usability in complex situations. This is of exceptional importance for apps dealing with the treatment of life-threatening events such as cardiac arrest.

Integrating cross-border emergency medicine systems: Securing future preclinical medical workforce for remote medical services.

The European Union intends to enable its citizens to interact across borders in relevant areas of society and culture to further integrate neighboring regions. Medicine has not been at the core of recent EU-funded efforts in central Europe, partially due to significant differences in health care administration, delivery, reimbursement, and culture. However, impeding changes in social structure and centralization of specialized care warrant changes in preclinical administration of medical care, which are already transforming practices across developed countries in central Europe. Moreover, demographic and social changes are transforming not only patients but also health care providers, thus leading to an increased need for specialized medical personnel, particularly in regions close to formerly secluding borders. The EU-funded cooperation project presented in this article is located in the Euroregion Pomerania, which consists of northeastern Germany and northwestern Poland. This project emerged because of the need to solve practical emergency medicine-related problems for many years, which brought partners together. Unfortunately, administrative and medical interaction has not become significantly easier with Poland joining the Schengen area in 2007 and, subsequently, initial international contracts regarding, among other things, emergency medicine being negotiated and signed thereafter. Three different interdependent areas of cooperation within the project deal with key aspects of an improved and eventually integrated cooperation. An accepted clarification of administrative and legal foundations - or the lack and thus the need thereof - needs to be defined. Specialized language and simulation-based education and practice sessions employing modern technology throughout will be introduced to the entire region. Finally, the pre-existing and developing acceptance and sustainability aspects of personnel involved in the aforementioned actions and stakeholders on both sides of the border will be evaluated. In essence, the project focuses on a multimodal improvement of professional cooperation of key providers of emergency medicine services in the Euroregion Pomerania. Thereby, it aims to improve infrastructure; interpersonal and professional skills of involved personnel, administrative, and cultural relations; and eventually identification of specialized personnel with their workplace and region to secure and retain important medical workforce in an otherwise remote area on both sides of a formerly secluded border.

A better understanding of ambulance personnel's attitude towards real-time resuscitation feedback.

OBJECTIVE: High-quality chest compressions during cardiopulmonary resuscitation (CPR) play a significant role in surviving cardiac arrest. Chest-compression quality can be measured and corrected by real-time CPR feedback devices, which are not yet commonly used. This article looks at the acceptance of such systems in comparison of equipped and unequipped personnel. DESIGN: Two groups of emergency medical services' (EMS) personnel were interviewed using standardized questionnaires. SETTING: The survey was conducted in the German cities Dortmund and Münster. PARTICIPANTS: Overall, 205 persons participated in the survey: 103 paramedics and emergency physicians from the Dortmund fire service and 102 personnel from the Münster service. INTERVENTION: The staff of the Dortmund service were not equipped with real-time feedback systems. The test group of equipped personnel of the ambulance service of Münster Fire brigade uses real-time feedback systems since 2007. MAIN OUTCOME MEASURE: What is the acceptance level of real-time feedback systems? Are there differences between equipped and unequipped personnel? RESULTS: The total sample is receptive towards real-time feedback systems. More than 80% deem the system useful. However, this study revealed concerns and prejudices by unequipped personnel. Negative ratings are significantly lower at the Münster site that is experienced with the use of the real-time feedback system in contrast to the Dortmund site where no such experience exists-the system's use in daily routine results in better evaluation than the expectations of unequipped personnel. CONCLUSIONS: Real-time feedback systems receive overall positive ratings. Prejudices and concerns seem to decrease with continued use of the system.

Predicting ROSC in out-of-hospital cardiac arrest using expiratory carbon dioxide concentration: Is trend-detection instead of absolute threshold values the key?

AIM: Guidelines recommend detecting return of spontaneous circulation (ROSC) by a rising concentration of carbon dioxide in the exhalation air. As CO2 is influenced by numerous factors, no absolute cut-off values of CO2 to detect ROSC are agreed on so far. As trends in CO2 might be less affected by influencing factors, we investigated an approach which is based on detecting CO2-trends in real-time. METHODS: We conducted a retrospective case-control study on 169 CO2 time series from out of hospital cardiac arrests resuscitated by Muenster City Ambulance-Service, Germany. A recently developed statistical method for real-time trend-detection (SCARM) was applied to each time series. For each series, the percentage of time points with detected positive and negative trends was determined. RESULTS: ROSC time series had larger percentages of positive trends than No-ROSC time series (p=0.003). The median percentage of positive trends was 15% in the ROSC time series (IQR: 5% to 23%) and 7% in the No-ROSC time series (IQR: 3% to 14%). A receiver operating characteristic (ROC) analysis yielded an optimal threshold of 13% to differentiate between ROSC and No-ROSC cases with a specificity of 58.4% and sensitivity of 73.9%; the area under the curve was 63.5%. CONCLUSION: Patients with ROSC differed from patients without ROSC as to the percentage of detected CO2 trends, indicating the potential of our real-time trend-detection approach. Since the study was designed as a proof of principle and its calculated specificity and sensitivity are low, more research is required to implement CO2-trend-detection into clinical use.

Senior citizens as rescuers: Is reduced knowledge the reason for omitted lay-resuscitation-attempts? Results from a representative survey with 2004 interviews.

OBJECTIVE: Resuscitation (CPR) provided by a bystander prior to the arrival of the emergency services is a beneficial factor for surviving a cardiac arrest (CA). Our registry-based data show, that older patients receive bystander-CPR less frequently. Little is known on possible reasons for this finding. We sought to investigate the hypothesis that awareness of CPR measures is lower in older laypersons being a possible reason for less CPR-attempts in senior citizens. METHODS: 1206 datasets on bystander resuscitations actually carried out were analyzed for age-dependent differences. Subsequently, we investigated whether the knowledge required carrying out bystander-CPR and the self-confidence to do so differ between younger and older citizens using computer-assisted telephone interviewing. 2004 interviews were performed and statistically analyzed. RESULTS: A lower level of knowledge to carry out bystander-CPR was seen in older individuals. For example, 82.4% of interviewees under 65 years of age, knew the correct emergency number. In this group, 66.6% named CPR as the relevant procedure in CA. Among older individuals these responses were only given by 75.1% and 49.5% (V = 0.082; P < 0.001 and V = 0.0157; P < 0.001). Additionally, a difference concerning participants' confidence in their own abilities was detectable. 58.0% of the persons younger than 65 years were confident that they would detect a CA in comparison to 44.6% of the participants older than 65 years (V = 0.120; P < 0.001). Similarly, 62.7% of the interviewees younger than 65 were certain to know what to do during CPR compared to 51.3% of the other group (V = 0.103; P < 0.001). CONCLUSIONS: Lower levels of older bystanders' knowledge and self-confidence might provide an explanation for why older patients receive bystander-CPR less frequently. Further investigation is necessary to identify causal connections and optimum ways to empower bystander resuscitation.

Systemic lidocaine in surgical procedures: effects beyond sodium channel blockade.

PURPOSE OF REVIEW: This review presents current data on the systemic administration of lidocaine. The focus is on studies in the perioperative setting. In addition, there is a brief look at experimental data on the effect of lidocaine at the molecular level. RECENT FINDINGS: Several recent randomized prospective studies have reported lower postoperative pain values and less opioid administration in lidocaine groups in comparison with control groups receiving NaCl. However, there are conflicting data particularly in relation to patients undergoing nonabdominal surgery and on effects on postoperative resumption of bowel motility and hospital discharge times. Unfortunately, hardly any studies have investigated the effects of systemic lidocaine in comparison with epidural anesthesia. At the molecular level, a number of receptors and signal transduction cascades have been identified. SUMMARY: Positive effects on postoperative pain, as well as on bowel motility and hospital discharge time, have regularly been observed. However, contradictory findings have also been published. As almost all of the studies only include very small patient numbers, large multicenter investigations are needed.

High proportions of CD4⁺ T cells among residual bone marrow T cells in childhood acute lymphoblastic leukemia are associated with favorable early responses.

Residual nonmalignant T cells in the bone marrow of patients with acute leukemias may be involved in active immune responses to leukemic cells. Here, we investigated the phenotypic signature of T cells present at diagnosis in 39 pediatric patients with acute lymphoblastic leukemia (ALL) treated within standardized ALL-BFM study protocols. Previously described age associations of lymphocyte subpopulations in the peripheral blood of healthy children were reproduced in leukemic bone marrow. Analysis of individual lymphocyte parameters and risk-associated variables using univariate linear regression models revealed a correlation of higher CD4/CD8 ratios at diagnosis with a favorable bone marrow response on day 15. Separate analysis of CD4⁺ cells with the CD4⁺CD25(hi)FoxP3⁺ T(reg) cell phenotype showed that the association was caused by non-T(reg) CD4⁺ cells. The association of higher CD4/CD8 ratios with a favorable bone marrow response on day 15 of treatment persisted in a cohort extended to 69 patients. We conclude that CD4⁺ non-T(reg) cells in leukemic bone marrow at diagnosis may have a role in early response to treatment. Prospective analysis of the CD4/CD8 ratio in a large cohort of pediatric patients is now needed. Moreover, future experiments will establish the functional role of the individual T cell subsets in immune control in pediatric ALL.