Biomedical subjects

Robert Swor

Publications and source records attributed to Robert Swor.

14 recordsLinked to original sources

PubMed2006

Outcomes from out-of-hospital cardiac arrest in Detroit.

OBJECTIVE: To determine the out-of-hospital cardiac arrest survival rate, and prevalence of modifiable factors associated with survival, in Detroit, Michigan, over a 6-month period of time in 2002. METHODS: A retrospective review of all out-of-hospital cardiac arrests responded to by the Detroit Fire Department, Division of Emergency Medical Services. All elements of the EMS runsheet were transcribed to a database for analysis. Patient hospital records were reviewed to determine survival to hospital admission. All survivors to hospital admission were surveyed later in the Michigan Department of Vital Records death registry search. RESULTS: During this study timeframe, there were 538 confirmed out-of-hospital cardiac arrests within the City of Detroit, of which 67 were excluded for being dead on scene [51 (12.5%)] or having no available hospital records [16 (3.0%)]. Of the remaining 471 patients, 443 (94.1%) died before hospital admission. Only 44 (9.9%) of the 471 patients had a first recorded rhythm of ventricular fibrillation (VF), and 339 (76.5%) were asystolic. Of the 28 patients who survived to hospital admission, only 2 (7.1%) were noted to have a first rhythm of VF, and 15 (53.6%) were asystolic. Only one patient survived to hospital discharge. CONCLUSIONS: In this urban setting, out-of-hospital cardiac arrest is an almost uniformly fatal event.

Adolescent↗

PubMed2006

Emergency medical service providers' experience with family presence during cardiopulmonary resuscitation.

OBJECTIVE: To describe emergency medical service providers' experiences with family member presence during resuscitation, and to determine whether those experiences are similar within urban and suburban settings. METHODS: We conducted a personally distributed survey of a convenience sample of urban and suburban emergency medical service (EMS) providers presenting to two Midwestern Emergency Departments. Providers were questioned as to their experiences with resuscitating patients in the presence of family members. RESULTS: There were 128 respondents to the survey (59 urban and 69 suburban), of which 70.1% were EMT-Paramedics. No provider who was approached refused participation. Nearly all (122) had performed CPR in the presence of family members, with most (77%) performing greater than 20. Subjects averaged 12.3 years of experience. The majority of urban and suburban providers felt it was inappropriate for family to witness resuscitations (75.9% versus 60.3%, respectively; p=0.068). Many providers reported feeling uncomfortable with family presence (31.5% urban versus 44.8% suburban; p=0.136), and few preferred that family witness the resuscitation (13.2% urban versus 15.4 suburban; p=0.738). A minority of providers believed that family were better prepared to accept the death of the patient (37.0% urban versus 37.6% suburban; p=0.939). Approximately half felt comfortable providing emotional support (66.0% urban versus 53.7% suburban; p=0.173). Many felt that family caused a negative impact during resuscitation (53.7% urban and 36.8% suburban; p=0.061). Urban providers more often reported feeling threatened by family members during resuscitation (66.7% versus 39.7%; p=0.003), and felt that family often interfered with their ability to perform resuscitations (35.6% versus 16.4%, p=0.014). CONCLUSIONS: EMS providers have substantial experience with family witnessed resuscitations, are uncomfortable about their presence, and often must provide support for families. While urban providers tended to report more negative experiences and perceptions, there were minimal differences between the two groups.

Adult↗

PubMed2006

The relationship between the hospital setting and perceptions of family-witnessed resuscitation in the emergency department.

OBJECTIVE: To compare the support for, and perceptions of, family-witnessed resuscitation (FWR) in urban and suburban emergency departments (ED). METHODS: A convenience sample of ED personnel from two urban and two suburban midwestern hospitals in the United States were surveyed. Survey questions assessed respondents' opinions and experiences regarding the presence of family members during a resuscitation attempt. Data analysis was conducted using descriptive statistics, 95% confidence intervals (CI), and chi2 tests. RESULTS: There were 218 respondents to the survey (108 urban, 110 suburban) of which the majority (63.3%) were female, and a mean (S.D.) age of 36.9 (10.2). The majority [131 (60.1%)] were health care providers (i.e. physicians, nurses, and physician assistants) while the remainder included support staff (i.e. security, pastoral care, and social workers). Half (50.9%; 95% CI: 44.3-57.6) of all ED personnel felt it was appropriate for an escorted family member to be allowed to be present during a resuscitation attempt. However, ED personnel of urban settings were less likely to support FWR (38.9% urban versus 62.7% suburban; p < 0.001). Likewise, fewer urban than suburban personnel thought that the psychological impact of witnessing a failed resuscitation attempt would be beneficial for a family member (37.6% versus 61.7%; respectively, p = 0.001). Of note, a minority, yet substantial percentage of all ED personnel believed that the practice would increase the potential for malpractice litigation (28.7% urban versus 21.8% suburban; p = 0.242). CONCLUSION: Overall, there is divided support among ED personnel for FWR. The hospital setting appears to influence this support strongly, as well as the perceived benefit of FWR.

Adult↗

PubMed2006

CPR training and CPR performance: do CPR-trained bystanders perform CPR?

OBJECTIVES: To determine factors associated with cardiopulmonary resuscitation (CPR) provision by CPR-trained bystanders and to determine factors associated with CPR performance by trained bystanders. METHODS: The authors performed a prospective, observational study (January 1997 to May 2003) of individuals who called 911 (bystanders) at the time of an out-of-hospital cardiac arrest. A structured telephone interview of adult cardiac-arrest bystanders was performed beginning two weeks after the incident. Elements gathered during interviews included bystander and patient demographics, identifying whether the bystander was CPR trained, when and by whom the CPR was performed, and describing the circumstances of the event. If CPR was not performed, we asked the bystanders why CPR was not performed. Logistic regression was used to calculate odds ratios and 95% confidence intervals (95% CI) for factors associated with CPR performance. RESULTS: Of 868 cardiac arrests, 684 (78.1%) bystander interviews were completed. Of all bystanders interviewed, 69.6% were family members of the victims, 36.8% of the bystanders had more than a high-school education, and 54.1% had been taught CPR at some time. In 21.2% of patients, the bystander immediately started CPR, and in 33.6% of cases, someone started CPR before the arrival of emergency medical services (EMS). Important overall predictors of CPR performance were the following: witnessed arrest (OR = 2.3; 95% CI = 1.4 to 3.8); bystander was CPR trained (OR = 6.6; 95% CI = 3.5 to 12.5); bystander had more than a high-school education (OR = 2.0; 95% CI = 1.2 to 3.1), or arrest occurred in a public location (OR = 3.1; 95% CI = 1.7 to 5.8). These variables were significant predictors of CPR performance among CPR-trained bystanders, as was CPR training within five years (OR = 4.5; 95% CI = 2.8 to 7.3). Common reasons that the CPR-trained bystanders cited for not performing CPR were the following: 37.5% stated that they panicked, 9.1% perceived that they would not be able to do CPR correctly, and 1.1% thought that they would hurt the patient. Surprisingly, only 1.1% objected to performing mouth-to-mouth resuscitation. CONCLUSIONS: A minority of CPR-trained bystanders performed CPR. CPR provision was more common in CPR-trained bystanders with more than a high-school education and when CPR training had been within five years. Previously espoused reasons for not doing CPR (mouth-to-mouth, infectious-disease risk) were not the reasons that bystanders cited for not doing CPR. Further work is needed to maximize CPR provision after CPR training.

Adult↗

PubMed2005

Predictors of cardiopulmonary resuscitation and automated external defibrillator skill retention.

BACKGROUND: Few data exist regarding the retention of cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) skills over time in relationship to characteristics of lay volunteer responders, training, or risk of exposure to victims. The purpose of this study was to describe the characteristics associated with adequate CPR and AED skill retention. METHODS AND RESULTS: Skill retention was tested 3 to 18 months (mean 6.9 +/- 3.5 months) after initial training. Instructors judged adequacy of performance of essential CPR or AED skills and provided an overall assessment (adequate/inadequate), which was used as the outcome. Data on 7261 laypersons trained in CPR (4358 also received AED training) in 24 sites across the United States and Canada were available from the Public Access Defibrillation (PAD) Trial. Characteristics of the volunteers, classes, and facilities were evaluated as predictors of performance adequacy. Adjusting for site, intervention assignment (CPR-only or CPR + AED), and time since initial training, volunteer characteristics associated with adequate CPR performance were age (OR 0.78 per 10-year increment), male sex (OR 1.44), minority (OR 0.62), married (OR 1.35), prior emergency experience (OR 1.66), prior CPR class (OR 1.68), prior advanced training (OR 1.59), and extracurricular CPR training (OR 1.91) (all P < .05). Characteristics associated with AED performance included age (OR 0.69), college education (OR 1.34), and native language other than English (OR 0.51) (all P < .05). CONCLUSIONS: Certain subgroups of lay volunteers may need targeted outreach programs in CPR and AED use, classes with longer training time, more practice, or more intense retraining to maintain their CPR and/or AED skills.

Adult↗

PubMed2005

Potential impact of a targeted cardiopulmonary resuscitation program for older adults on survival from private-residence cardiac arrest.

OBJECTIVE: Traditional cardiopulmonary resuscitation (CPR) training programs do not target older adults who are most likely to witness private-residence cardiac arrests and do not reliably result in a bystander who is likely to perform CPR in the event of an arrest. This study was performed to compare targeted CPR training programs for older adults (older than 50 years) that 1) increase numbers of CPR-trained bystanders of private-residence cardiac arrest or 2) increase the percentage of trained bystanders of private-residence cardiac arrest who perform CPR. A simultaneous outcome was to estimate the minimal significant survival benefit associated with each of the training programs. METHODS: A probabilistic simulation model was developed in Fortran95 that incorporated key out-of-hospital cardiac arrest elements, including witnessed arrests, CPR-trained witness, CPR provision, and impact of CPR on ventricular fibrillation. Input data were derived from published or publicly available data, including a large prospective cohort study of outcomes in Oakland County, MI. Monte Carlo simulation (n = 10,000) and sensitivity analyses (n = 40) were used to assess median and the empiric 95% confidence intervals [CIs] for incremental survival with either intervention. RESULTS: The baseline model, calibrated to the characteristics of the input-data community, established that, for private-residence cardiac arrests, 40.8% of cardiac arrest bystanders were trained in CPR; however, only 25.7% performed CPR. This yielded 4.81% survival (95% CI = 4.72 to 4.89). Modeling the impact on the baseline training level with increased CPR performance among trainees indicated that 75% of private-residence trained bystanders would need to perform CPR in order to reach a minimally significant improvement in survival (5.02%; 95% CI = 4.94 to 5.15). Similarly, targeted CPR training that would result in a significant survival benefit (to 5.01%; 95% CI = 4.93 to 5.09) would require that 70.8% of bystanders be trained. CONCLUSIONS: CPR training programs that focus on yielding 75% of trainees who perform CPR in the event of witnessing an arrest would have equivalent results to mass CPR training programs that result in 70% of bystanders being trained in CPR. However, the minimal survival benefit associated with these programs (around 0.2%) may prove either method costly with minimal effect.

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PubMed2003

A randomized controlled trial of chest compression only CPR for older adults-a pilot study.

UNLABELLED: Older people are trained infrequently in cardiopulmonary resuscitation (CPR), yet are more likely to witness a cardiac arrest. Older people who are CPR trained perform CPR when witnessing a cardiac arrest. OBJECTIVE: To assess whether elderly adults (>55 years) who receive chest-compression only cardiopulmonary resuscitation (CC-CPR) training display equivalent skill retention rates compared with those who receive traditional CPR instruction. We also identified factors associated with 3 months skill retention at 3 months in both groups. METHODS: Older adults in a suburban hospital Older Adult Services program were invited to participate in an experimental CPR course. The 2 h course was modelled after the AHA Friends and Family course, and used one of two standardized video scenarios. Seventy four subjects were randomized to CC-CPR (n=36) or traditional CPR (n=38) training. Participation consisted of initial training, followed by a 3 months return videotaped assessment. Three months skill competence was assessed either by consensus between two video evaluators, or the on-site evaluator. Chi square and Kappa tests were used for analysis, and unadjusted odds ratios and 95% confidence intervals are reported. RESULTS: Skill retention assessments were completed on 29 (81%) CC-CPR and 26 (68%) CPR trainees. Subjects were elderly (71.5+/-6.69 years), and had a high rate of previous CPR training (58.0%). Groups were similar in demographic characteristics. After training, participants exhibited high rates of perceived competence (86.4%), although the overall 3 months skill retention was low (43.6%). CC-CPR training resulted in equivalent skill retention rates as compared with traditional CPR training (51.7 vs. 44.4%; P=0.586). No participant factors were associated with skill retention, including age, previous CPR training, education level, medical history, or perceived physical ability to perform. CONCLUSION: We identified low rates of CPR skill retention in this elderly population. CC-CPR instruction was associated with equivalent skill retention rates compared with traditional CPR instruction. No demographic factors were associated with successful skill retention.

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PubMed2003

Perceived self-efficacy in performing and willingness to learn cardiopulmonary resuscitation in an elderly population in a suburban community.

BACKGROUND: Older persons are the group most likely to respond to cardiac arrests in private residences. OBJECTIVE: To characterize the knowledge about, attitudes toward, and perceived self-efficacy of older persons in learning and providing cardiopulmonary resuscitation. METHODS: A total of 2743 surveys were mailed to adults 55 years and older who resided in a single Michigan suburb. Data were collected on demographics, medical history, training in and willingness to provide cardiopulmonary resuscitation, and concerns about providing this intervention. RESULTS: The 631 persons (24.6%) who responded were elderly (mean age, 73.5 years) and had a mean of 1.7 occupants per household. More than one third lived alone. Of all respondents, 275 (43.6%) had received training in cardiopulmonary resuscitation, 370 (58.6%) indicated a willingness to learn cardiopulmonary resuscitation, and 412 (65.3%) thought that they had the ability to perform this intervention. Respondents 80 years or younger were significantly more likely than respondents more than 80 years old to be willing to learn cardiopulmonary resuscitation (65.7% vs 19.0%, P < .001) and perceived themselves as able to perform it (73.0% vs 34.0%, P < .001). The absence of mouth-to-mouth ventilation as part of training had minimal impact on the willingness of either age group to receive training (61.2% vs 58.6%, P = .19). Perceived ability to learn and perform cardiopulmonary resuscitation did not vary with the medical history of the respondent or the respondent's spouse. CONCLUSION: Adults 56 to 80 years old perceive themselves as able to perform cardiopulmonary resuscitation and are interested in receiving training.

Aged↗

PubMedDate not supplied

Estimating cost-effectiveness of mass cardiopulmonary resuscitation training strategies to improve survival from cardiac arrest in private locations.

INTRODUCTION: Most cardiopulmonary resuscitation (CPR) trainees are young, and most cardiac arrests occur in private residences witnessed by older individuals. OBJECTIVE: To estimate the cost-effectiveness of a CPR training program targeted at citizens over the age of 50 years compared with that of current nontargeted public CPR training. METHODS: A model was developed using cardiac arrest and known demographic data from a single suburban zip code (population 36,325) including: local data (1997-1999) regarding cardiac arrest locations (public vs. private); incremental survival with CPR (historical survival rate 7.8%, adjusted odds ratio for CPR 2.0); arrest bystander demographics obtained from bystander telephone interviews; zip code demographics regarding population age and distribution; and 12.50 dollars per student for the cost of CPR training. Published rates of CPR training programs by age were used to estimate the numbers typically trained. Several assumptions were made: 1) there would be one bystander per. arrest; 2) the bystander would always perform CPR if trained; 3) cardiac arrest would be evenly distributed in the population; and 4) CPR training for a proportion of the population would proportionally increase CPR provision. Rates of arrest, bystanders by age, number of CPR trainees needed to result in increased arrest survival, and training cost per life saved for a one-year study period were calculated. RESULTS: There were 24.3 cardiac arrests per year, with 21.9 (90%) occurring in homes. In 66.5% of the home arrests, the bystander was more than 50 years old. To yield one additional survivor using the current CPR training strategy, 12,306 people needed to be trained (3,510 bystanders aged < or = 50 years and 8,796 bystanders aged > 50 years), which resulted in CPR provision to 7.14 additional patients. The training cost per life saved for a bystander aged < or = 50 years was 313,214 dollars, and that for a bystander aged > 50 years was 785,040 dollars. Using a strategy of training only those < or = 50 years, 583 elders per cardiac arrest would need to be trained, with a cost of 53,383 dollars per life saved. CONCLUSION: Using these assumptions, current CPR training strategy is not a cost-effective intervention for home cardiac arrests. The high rate of elders witnessing CPR mandates focused CPR interventions for this population.

Aged↗

PubMedDate not supplied

Few emergency medical services patients with lower-extremity fractures receive prehospital analgesia.

UNLABELLED: Previous literature has identified prehospital pain management as an important emergency medical services (EMS) function, and few patients transported by EMS with musculoskeletal injuries receive prehospital analgesia (PA). OBJECTIVES: 1) To describe the frequency with which EMS patients with lower-extremity and hip fracture receive prehospital and emergency department (ED) analgesia; 2) to describe EMS and patient factors that may affect administration of PA to these patients; and 3) to describe the time interval between EMS and ED medication administrations. METHODS: This was a four-month (April to July 2000) retrospective study of patients with a final hospital diagnosis of hip or lower-extremity fracture who were transported by EMS to a single suburban community hospital. Data including patient demographics, fracture type, EMS response, and treatment characteristics were abstracted from review of EMS and ED records. Patients who had ankle fractures, had multiple traumatic injuries, were under the age of 18 years, or did not have fractures were excluded. RESULTS: One hundred twenty-four patients met inclusion criteria. A basic life support (BLS)-only response was provided to 20 (16.0%). Another 38 (38.4%) received an advanced life support (ALS) response and were triaged to BLS transport. Of all the patients, 22 (18.3%) received PA. Patients who received PA were younger (64.0 vs. 77.3 years, p < 0.001) and more likely to have a lower-extremity fracture other than a hip fracture (31.8% vs. 10.7%, p < 0.004). Of all patients, 113 (91.1%) received ED analgesia. Patients received analgesia from EMS almost 2.0 hours sooner that in the ED (mean 28.4 +/- 36 min vs. 146 +/- 74 min after EMS scene arrival, p < 0.001). CONCLUSION: A minority of the study group received PA. Older patients and patients with hip fracture are less likely to receive PA. It is unclear whether current EMS system design may adversely impact administration of PA. Further work is needed to clarify whether patient need or EMS practice patterns result in low rates of PA.

Age Factors↗

PubMedDate not supplied

Performance measurements in emergency medical services.

With the strong encouragement of leading health care agencies, business principles are being implemented throughout health care, including emergency medical services (EMS). The reason is simple--quality of care can be enhanced by incorporating the management concepts of continuous quality improvement (CQI). The CQI process couples carefully identified, measurable performance indicators with information systems to monitor, analyze, and trend data. Benchmarking outcomes with other EMS systems allows the identification of "best practices" and the evolution of standards. Emergency medical services professionals must actively participate with the broader health care community in creating performance measurements to ensure that high-quality care is delivered consistently.

Benchmarking↗

PubMedDate not supplied

Current issues in cardiopulmonary resuscitation.

Current Advanced Cardiac Life Support (ACLS) guidelines and emergency medical services (EMS) clinical protocols usually recommend immediate defibrillation for victims of out-of-hospital cardiac arrest who have ventricular fibrillation (VF). However, animal studies and results from a small number of clinical investigations now suggest that a short period of chest compressions or ACLS procedures delivered before defibrillation may improve the outcome of patients with prolonged VF. Although the basic science and clinical data supporting a chest-compression-first procedure are compelling, large, multicenter randomized trials are still necessary to determine whether such protocols do indeed improve outcome. In current EMS dispatch practice, traditional cardiopulmonary resuscitation (CPR) instructions are given when needed to bystanders who report a possible cardiac arrest. Recent literature has shown that in certain circumstances, CPR instructions involving chest compressions alone may be given more quickly and can yield an equivalent, if not better, chance of survival. Although this practice is controversial, the general consensus is that any CPR is better than none at all. Therefore, telephone CPR protocols that recommend the immediate initiation of chest compressions may be preferred, particularly for callers who have no previous training in CPR.

Advanced Cardiac Life Support↗

PubMedDate not supplied

Prehospital pain management in children suffering traumatic injury.

UNLABELLED: Prehospital pain management has become an important emergency medical services (EMS) patient care issue. OBJECTIVES: To describe the frequency of EMS and emergency department (ED) analgesic administration to injured children; to describe factors associated with the administration of analgesia by EMS; and to assess whether children with lower-extremity fractures receive analgesia as frequently as do adults with similar injuries. METHODS: This was a retrospective study of children (age < 21 years) who were transported by EMS between January 2000 and June 2002 and had a final hospital diagnosis of extremity fractures or burns. Secondarily, children with lower-extremity fractures were compared with a cohort of EMS-transported adults with similar injuries and transported during the same study period. Receipt of and time of parenteral analgesia were recorded. RESULTS: Seventy-three children met the inclusion criteria. The mean (range) age of this sample was 12.4 (0.9-21) years, with only four patients aged < 5 years. A majority of the patients were male (49/73, 67.1%) and sustained femur (20/73, 27.4%) or tibia/fibula (26/73, 35.6%) fractures. Few pediatric patients received prehospital analgesia (16/73, 21.9%), while a majority received analgesia in the ED (58/73, 79.4%). Prehospital analgesia was associated with earlier patient treatment than that administered in the ED (22.3 +/- 5.9 min vs. 88.3 +/- 38.2 min). Comparing children (n = 33) with adults (n = 76) with similar lower-extremity fractures, a small insignificant difference was found in the rate of prehospital analgesia between children and adults (7/33, 21.2%, vs. 20/56, 26.3%). CONCLUSION: Few pediatric patients receive prehospital analgesia, although most ultimately received ED analgesia. Few factors were identified that could be associated with EMS oligoanalgesia. No difference was found between children and adults in the rates of EMS analgesia.

Adolescent↗

PubMedDate not supplied

Prehospital 12-lead ECG: efficacy or effectiveness?

INTRODUCTION: Previous literature has documented that prehospital 12-lead electrocardiography (ECG) decreases the time to reperfusion in patients with an acute ST-segment elevation myocardial infarction (STEMI). OBJECTIVE: To compare time to ECG, time to angioplasty suite (laboratory), and time to reperfusion in emergency medical services (EMS) STEMI patients, who received care through three different processes. METHODS: The setting was a large suburban community teaching hospital with emergency department (ED)-initiated single-page acute myocardial infarction (AMI) team activation for STEMI patients. The population was STEMI patients transported by EMS from January 2003 to October 2005. Not all EMS agencies had prehospital 12-lead ECG capability. Paramedics interpret and verbally report clinical assessment and ECG findings via radio. The AMI team is activated at the discretion of the emergency physician 1) before patient arrival to the ED based on EMS assessment, 2) after ED evaluation with EMS ECG, or 3) after ED evaluation and ED ECG. Time intervals were calculated from ED arrival. To assess the impact of interventions on performance targets, we also report the proportion of patients who arrived in laboratory within 60 minutes and reperfusion within 90 minutes of arrival. Parametric and nonparametric statistics are used for analysis. RESULTS: During the study period, there were 164 STEMI patients transported by EMS; mean age was 66.1 years, and 56% were male. Of these, 93 (56.7%) had an EMS ECG and 31 (33%) had AMI team activation before ED arrival. Mean time to laboratory for all patients was 49.8 +/- 34.4 minutes and time to reperfusion was 93.2 +/- 34.5 min. Patients with prearrival activation were transported to laboratory sooner (mean, 24.3 vs. 53. 4 minutes; p < 0.001) and received reperfusion sooner than all other patients (mean, 70.4 vs. 96.3 minutes; p = 0.007). More prearrival activation patients met performance targets to laboratory (96.7% vs. 73.7%; p = 0.009) and reperfusion (85.2% vs. 51.0%; p = 0.003). There was no difference in time to laboratory or to reperfusion for patients who received EMS ECG but no prearrival activation compared with those who received EMS transport alone. CONCLUSIONS: A minority of patients with EMS ECGs had prearrival AMI team activation. EMS ECGs combined with systems that activate hospital resources, but not EMS ECGs alone, decrease time to laboratory and reperfusion.

Aged↗