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Improving quality of intrapartum care will reduce intrapartum stillbirth and neonatal mortality, especially in resource-poor settings. Basic neonatal resuscitation can reduce intrapartum stillbirth and early neonatal mortality, if delivered in a high-quality health system, but there is a dearth of evidence on how to scale up such evidence-based interventions. We evaluated the scaling up of a quality improvement (QI) package for neonatal resuscitation on intrapartum-related mortality (intrapartum stillbirth and first day mortality) at hospitals in Nepal. We conducted a stepped-wedge cluster randomized controlled trial in 12 hospitals over a period of 18 months from April 14, 2017, to October 17, 2018. The hospitals were assigned to one of four wedges through random allocation. The QI package was implemented in a stepped-wedge manner with a delay of three months for each step. The QI package included improving hospital leadership on intrapartum care, building health workers' competency on neonatal resuscitation, and continuous facilitated QI processes in clinical units. An independent data collection system was set up at each hospital to gather data on mortality through patient case note review and demographic characteristics of women using semi-structured exit interviews. The generalized linear mixed model (GLMM) and multivariate logistic regression were used for analyses. During this study period, a total of 89,014 women-infant pairs were enrolled. The mean age of the mother in the study period was 24.0 ± 4.3 years, with 54.9% from disadvantaged ethnic groups and 4.0% of them illiterate. Of the total birth cohort, 54.4% were boys, 16.7% had gestational age less than 37 weeks, and 17.1% had birth weight less than 2,500 grams. The incidence of intrapartum-related mortality was 11.0 per 1,000 births during the control period and 8.0 per 1,000 births during the intervention period (adjusted odds ratio [aOR], 0.79; 95% CI, 0.69-0.92; p = 0.002; intra-cluster correlation coefficient [ICC], 0.0286). The incidence of early neonatal mortality was 12.7 per 1,000 live births during the control period and 10.1 per 1,000 live births during the intervention period (aOR, 0.89; 95% CI, 0.78-1.02; p = 0.09; ICC, 0.1538). The use of bag-and-mask ventilation for babies with low Apgar score (<7 at 1 minute) increased from 3.2% in the control period to 4.0% in the intervention period (aOR, 1.52; 95% CI, 1.32-1.77, p = 0.003). There were two major limitations to the study; although a large sample of women-infant pairs were enrolled in the study, the clustering reduced the power of the study. Secondly, the study was not sufficiently powered to detect reduction in early neonatal mortality with the number of clusters provided. These results suggest scaled-up implementation of a QI package for neonatal resuscitation can reduce intrapartum-related mortality and improve clinical care. The QI intervention package is likely to be effective in similar settings. More implementation research is required to assess the sustainability of QI interventions and quality of care. ISRCTN30829654.

In septic shock, the first few hours of care are critical for survival. In this study, two protocols for the care of patients with septic shock were compared with usual care with respect to 60-day mortality and other outcomes. There were no significant differences in outcome. There are more than 750,000 cases of severe sepsis and septic shock in the United States each year. 1 Most patients who present with sepsis receive initial care in the emergency department, and the short-term mortality is 20% or more. 2 , 3 In 2001, Rivers et al. reported that among patients with severe sepsis or septic shock in a single urban emergency department, mortality was significantly lower among those who were treated according to a 6-hour protocol of early goal-directed therapy (EGDT) than among those who were given standard therapy (30.5% vs. 46.5%). 4 On the basis of the premise that usual care . . .

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. 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. 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). 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. International Clinical Trials Registry Platform of the World Health Organisation and German Register of Clinical Trials (DRKS00009903), Registered 09 February 2016 (retrospectively registered).

Background A number of cardiopulmonary resuscitation (CPR) adjunct devices have been developed to improve the consistency and quality of manual chest compressions. We investigated whether a CPR feedback device would improve CPR quality and consistency, as well as patient survival. Methods We conducted a randomized controlled study of patients undergoing CPR for cardiac arrest in the mixed medical-surgical intensive care units of four academic teaching hospitals. Patients were randomized to receive either standard manual CPR or CPR using the Cardio First Angel™ CPR feedback device. Recorded variables included guideline adherence, CPR quality, return of spontaneous circulation (ROSC) rates, and CPR-associated morbidity. Results A total of 229 subjects were randomized; 149 were excluded; and 80 were included. Patient demographics were similar. Adherence to published CPR guidelines and CPR quality was significantly improved in the intervention group ( p  < 0.0001), as were ROSC rates (72 % vs. 35 %; p  = 0.001). A significant decrease was observed in rib fractures (57 % vs. 85 %; p  = 0.02), but not sternum fractures (5 % vs. 17 %; p  = 0.15). Conclusions Use of the Cardio First Angel™ CPR feedback device improved adherence to published CPR guidelines and CPR quality, and it was associated with increased rates of ROSC. A decrease in rib but not sternum fractures was observed with device use. Further independent prospective validation is warranted to determine if these results are reproducible in other acute care settings. Trial registration ClinicalTrials.gov identifier: NCT02394977 . Registered on 5 Mar 2015.

BackgroundNon-technical skills, such as task management, leadership, situational awareness, communication and decision-making refer to cognitive, behavioural and social skills that contribute to safe and efficient team performance. The importance of these skills during cardiopulmonary resuscitation (CPR) is increasingly emphasised. Nonetheless, the relationship between non-technical skills and technical performance is poorly understood. We hypothesise that non-technical skills become increasingly important under stressful conditions when individuals are distracted from their tasks, and investigated the relationship between non-technical and technical skills under control conditions and when external stressors are present.MethodsIn this simulator-based randomised cross-over study, 30 anaesthesiologists and anaesthesia residents from the VU University Medical Center, Amsterdam, the Netherlands, participated in two different CPR scenarios in random order. In one scenario, external stressors (radio noise and a distractive scripted family member) were added, while the other scenario without stressors served as control condition. Non-technical performance of the team leader and technical performance of the team were measured using the ‘Anaesthetists’ Non-technical Skill’ score and a recently developed technical skills score. Analysis of variance and Pearson correlation coefficients were used for statistical analyses.ResultsNon-technical performance declined when external stressors were present (adjusted mean difference 3.9 points, 95% CI 2.4 to 5.5 points). A significant correlation between non-technical and technical performance scores was observed when external stressors were present (r=0.67, 95% CI 0.40 to 0.83, p<0.001), while no evidence for such a relationship was observed under control conditions (r=0.15, 95% CI −0.22 to 0.49, p=0.42). This was equally true for all individual domains of the non-technical performance score (task management, team working, situation awareness, decision-making).ConclusionsDuring CPR with external stressors, the team’s technical performance is related to the non-technical skills of the team leader. This may have important implications for training of CPR teams.

Objective To investigate whether real-time audio and visual feedback during cardiopulmonary resuscitation outside hospital increases the proportion of subjects who achieved prehospital return of spontaneous circulation.Design A cluster-randomised trial.Subjects 1586 people having cardiac arrest outside hospital in whom resuscitation was attempted by emergency medical services (771 procedures without feedback, 815 with feedback).Setting Emergency medical services from three sites within the Resuscitation Outcomes Consortium in the United States and Canada.Intervention Real-time audio and visual feedback on cardiopulmonary resuscitation (CPR) provided by the monitor-defibrillator.Main outcome measure Prehospital return of spontaneous circulation after CPR.Results Baseline patient and emergency medical service characteristics did not differ between groups. Emergency medical services muted the audible feedback in 14% of cases during the period with feedback. Compared with CPR clusters lacking feedback, clusters assigned to feedback were associated with increased proportion of time in which chest compressions were provided (64% v 66%, cluster-adjusted difference 1.9 (95% CI 0.4 to 3.4)), increased compression depth (38 v 40 mm, adjusted difference 1.6 (0.5 to 2.7)), and decreased proportion of compressions with incomplete release (15% v 10%, adjusted difference −3.4 (−5.2 to −1.5)). However, frequency of prehospital return of spontaneous circulation did not differ according to feedback status (45% v 44%, adjusted difference 0.1% (−4.4% to 4.6%)), nor did the presence of a pulse at hospital arrival (32% v 32%, adjusted difference −0.8 (−4.9 to 3.4)), survival to discharge (12% v 11%, adjusted difference −1.5 (−3.9 to 0.9)), or awake at hospital discharge (10% v 10%, adjusted difference −0.2 (−2.5 to 2.1)).Conclusions Real-time visual and audible feedback during CPR altered performance to more closely conform with guidelines. However, these changes in CPR performance were not associated with improvements in return of spontaneous circulation or other clinical outcomes.Trial Registration Clinical Trials NCT00539539

Objectives To evaluate the resuscitative effects of mechanical and manual chest compression in patients with out-of-hospital cardiac arrest (OHCA). Methods All randomized controlled and cohort studies comparing the effects of mechanical compression and manual compression on cardiopulmonary resuscitation in OHCA patients were retrieved from the Cochrane Library, PubMed, EMBASE, and Ovid databases from the date of their establishment to January 14, 2019. The included outcomes were as follows: the return of spontaneous circulation (ROSC) rate, the rate of survival to hospital admission, the rate of survival to hospital discharge, and neurological function. After evaluating the quality of the studies and summarizing the results, RevMan5.3 software was used for the meta-analysis. Results In total, 15 studies (9 randomized controlled trials and 6 cohort studies) were included. The results of the meta-analysis showed that there were no significant differences in the resuscitative effects of mechanical and manual chest compression in terms of the ROSC rate, the rate of survival to hospital admission and survival to hospital discharge, and neurological function in OHCA patients (ROSC: RCT: OR = 1.12, 95% CI (0.90, 1.39), P  = 0.31; cohort study: OR = 1.08, 95% CI (0.85, 1.36), P  = 0.54; survival to hospital admission: RCT: OR = 0.95, 95% CI (0.75, 1.20), P  = 0.64; cohort study: OR = 0.98 95% CI (0.79, 1.20), P  = 0.82; survival to hospital discharge: RCT: OR = 0.87, 95% CI (0.68, 1.10), P  = 0.24; cohort study: OR = 0.78, 95% CI (0.53, 1.16), P  = 0.22; Cerebral Performance Category (CPC) score: RCT: OR = 0.88, 95% CI (0.64, 1.20), P  = 0.41; cohort study: OR = 0.68, 95% CI (0.34, 1.37), P  = 0.28). When the mechanical compression group was divided into Lucas and Autopulse subgroups, the Lucas subgroup showed no difference from the manual compression group in ROSC, survival to admission, survival to discharge, and CPC scores; the Autopulse subgroup showed no difference from the manual compression subgroup in ROSC, survival to discharge, and CPC scores. Conclusion There were no significant differences in resuscitative effects between mechanical and manual chest compression in OHCA patients. To ensure the quality of CPR, we suggest that manual chest compression be applied in the early stage of CPR for OHCA patients, while mechanical compression can be used as part of advanced life support in the late stage.

Between 1/15,000–1/50,000 passengers suffer in-flight medical emergencies (IFME) with cardiac arrest accounting for 0.3 %. Confined space can have a negative impact on quality of chest compressions during cardiopulmonary resuscitation (CPR), thus we have conducted a randomized controlled study to find the most effective approach of performing CPR in a one – vs. two-rescuer method in a simulated airliner cabin. We randomized 20 healthcare professionals to perform a set of 10 min Basic Life Support (BLS, chest compressions and bag-mask-ventilation) in a one- vs. two-rescuer scenario and in confined space vs. open space in a randomized order using a full-body manikin. The primary outcome was compression depth as sensitive marker for differences in CPR-quality. The study was registered on clinicaltrials.gov (NCT02002481). Mixed ANOVAs with post-hoc false-discovery-rate adjusted pairwise comparisons indicated that one- vs. two-rescuer method showed differences in no-flow-time (confined: 8.05 ± 0.17 vs. 24.25 ± 1.05 s/2min and open space: 7.51 ± 0.02 vs. 21.31 ± 0.43 s/2min; p < 0.001) and missing releases (confined: 27.09 ± 5.55 vs. 46.64 ± 9.66 number/10 minutes and open space: 27.09 ± 2.44 vs. 43.36 ± 6.4 number/10minutes; p < 0.001). A confined space significantly elevated no-flow-time in the two-rescuer-method vs. the one-rescuer-method (24.24 ± 1.06 s/2min vs. 21.26 ± 0.44 s/2min; p < 0.001), whereas compression frequency and compression depth were different but still within the current recommendations of ERC/AHA in both methods per condition. Limited space in an airliner cabin has significant impact on no-flow-time in a two-rescuer-method. In case of CPR and limited access to the patient, we recommend a one-rescuer-method as first approach to ensure early and high-quality CPR for experienced personnel.

The American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) are nowadays recognized as the world's most authoritative resuscitation guidelines. Adherence to these guidelines optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite their availability, suboptimal quality of CPR is still common. Currently, the median hospital survival rate after pediatric in-hospital cardiac arrest is 36%, whereas it falls below 10% for out-of-hospital cardiac arrest. Among emerging information technologies and devices able to support caregivers during resuscitation and increase adherence to AHA guidelines, augmented reality (AR) glasses have not yet been assessed. In order to assess their potential, we adapted AHA Pediatric Advanced Life Support (PALS) guidelines for AR glasses. The study aimed to determine whether adapting AHA guidelines for AR glasses increased adherence by reducing deviation and time to initiation of critical life-saving maneuvers during pediatric CPR when compared with the use of PALS pocket reference cards. We conducted a randomized controlled trial with two parallel groups of voluntary pediatric residents, comparing AR glasses to PALS pocket reference cards during a simulation-based pediatric cardiac arrest scenario-pulseless ventricular tachycardia (pVT). The primary outcome was the elapsed time in seconds in each allocation group, from onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, as well as the time intervals between defibrillation attempts and drug doses, shock doses, and number of shocks. All these outcomes were assessed for deviation from AHA guidelines. Twenty residents were randomized into 2 groups. Time to first defibrillation attempt (mean: 146 s) and adherence to AHA guidelines in terms of time to other critical resuscitation endpoints and drug dose delivery were not improved using AR glasses. However, errors and deviations were significantly reduced in terms of defibrillation doses when compared with the use of the PALS pocket reference cards. In a total of 40 defibrillation attempts, residents not wearing AR glasses used wrong doses in 65% (26/40) of cases, including 21 shock overdoses >100 J, for a cumulative defibrillation dose of 18.7 Joules per kg. These errors were reduced by 53% (21/40, P<.001) and cumulative defibrillation dose by 37% (5.14/14, P=.001) with AR glasses. AR glasses did not decrease time to first defibrillation attempt and other critical resuscitation endpoints when compared with PALS pocket cards. However, they improved adherence and performance among residents in terms of administering the defibrillation doses set by AHA.

ObjectivePaediatric health providers and educators influence infant mortality through advocacy and training within families and communities. This research sought to establish the efficacy and training of two-finger versus two-thumb-encircling techniques for lone responder infant chest compressions with ventilations in initially trained infant caregivers.DesignThis is a randomised, cross-over educational intervention assessed on instrumented manikins using the 2015 guideline measures of quality infant cardiopulmonary resuscitation (CPR). Additional subjective data on the experience were collected through self-reporting.SettingNon-healthcare community organisations and secondary school classrooms.ParticipantsFourteen years or older, fluent in English and had not taken infant CPR in the last 5 years.InterventionsGroups of eight participants were randomised to learn one technique, practised and then tested for 8 min. After a 30 min rest, the group repeated the process using the other technique.Main outcome measuresMean chest compression depth and rate, compression fraction, and correct hand position; tiredness and pain as reported by the caregiver.ResultsThe two-thumb-encircling technique achieved a deeper mean compression depth over the 8 min period (2.0 mm, p<0.01), closer to the minimum recommendation of 40 mm; the two-finger technique achieved higher percentages of compression fraction and complete recoil. Caregivers preferred the two-thumb technique (64%), and of these 70% had long fingernails.ConclusionsThe two-thumb-encircling technique improved compression depth, over an 8 min scenario, and was preferred by caregivers. This adds to the existing literature on the advantages of two-thumb-encircling as a technique for lone and team infant CPR, which counters current guidelines.