SCCM Resource Library-Train in Vain? Evidence for the Impact of Guidelines and Training on CPR Outcomes

Video Transcription

All right, so the title of this one is Train and Vein, the Impact of Guidelines and Training on CPR Outcomes.  So I talked a little bit about the training that we've developed around the recovery guidelines.  What I'd like to do in this next, I'll try to make it 40 minutes so that you guys get a little break on time, is what we know about CPR training, whether guidelines make any  difference in outcomes, and what the best way to train is. So again, no disclosures. So as I said, we do have an online course that we sell. I do not get the revenue from that.  Sometimes I wish I did, but that revenue actually helps to support the American College of Veterinary  Emergency and Critical Care, and also some of it goes to Cornell, my employer, but I don't benefit directly from any of it.  OK, so thinking about the epidemiology of cardiopulmonary arrest, so this is a diagram that I use a lot.  I know Manu, I think I stole it from Manu, so Manu uses it a lot too, but I think it's informative really in thinking about our practice of CPR and what we know.  So this is relatively old data, but this is about 15,000 people within hospital cardiopulmonary arrest. At the time of the arrest, we initiate CPR.  At that time, they had about return of spontaneous circulation could be expected in about 45% of people.  And then in the post-cardiac arrest period, they lose another 60% or so, leading to overall discharge rates of about 17%.  This is a huge data set, lots of different causes of arrests, hard to know exactly how to interpret all of this.  Looking at what we know in veterinary medicine, unfortunately, we're still reliant on this one paper that was published back in 2009.  Manu is working hard with our CPR registry to try to collect more data so that we can update these numbers a little bit more.  But looking at that study, about 200 dogs and cats, we had a return of spontaneous circulation  between 35% and 45%, interestingly lower in cats than in dogs, which I don't understand because I feel like you should be able to do great quality CPR in cats, I just feel  like people give up on cats more easily. And then looking at the post-cardiac arrest phase, we lose another 80% to 85%, probably  a lot of those due to euthanasia, leading to very low discharge rates in our patients as well. So kind of dismal, our question is, can we do something to improve this?  I think the data that I presented just a minute ago from a new study from 2010 would suggest, yes, there's a lot that we could probably do to improve this, because even the basics  of basic life support, we seem to not have good consensus on, and we don't have a lot of people practicing to the level that we know can cause differences in outcomes.  So I think we have a lot of low-hanging fruit in veterinary medicine. So Manu mentioned this formula for survival in his talk, where we have to think about  how do we improve these outcomes. It starts with the medical science, we add in education to try to teach people the best  way to do things, and good, consistent local implementation so that people have access to it, and ultimately that's what leads to an improvement in survival.  So the medical science is the evidence-based guidelines, which we have done, and we're working on a new version of. So I think we've got the medical science down the best we can.  We have a lot of work to do in terms of improving that medical science, but we have a pretty good handle on it now.  And then really, this CPR training is where we get the local implementation and the educational efficiency associated with improving survival.  So the education piece of this, I think, is really important if we want to make a difference in outcomes in CPR. So we've sort of taken our first steps here, right?  We published guidelines in 2012. It's been quite a while now. It's been downloaded a lot. We have an algorithm. So in theory, everything should be fine, right?  Everybody should know how to do this. They follow the algorithm. We should see the numbers go up, and everything should be great.  But the question is, does it matter that we have guidelines? Do we actually have any evidence that having these guidelines in place can make a difference  in terms of outcomes from CPR? It turns out we don't have a lot of evidence of that. It's one of those things that I think most people think, well, if you know the best way  to do something and you do it the best way, things have got to get better, right? But when you look for the evidence for that, it's not so easy to find.  So the first study I could find really looking at this question of whether access to guidelines improves outcomes was published in 2018, so not the oldest data around, right?  And this was a retrospective study in three tertiary care facilities. They had 160 patients who met criterion here. They achieved ROSC in 75 of these patients.  Only 20 survived to discharge. But when they looked at the patients who achieved ROSC, and this was the mean number of deviations  from the guidelines, so they actually recorded these resuscitation attempts. And then they looked at how well people adhered to the guidelines.  If you looked at the survivors versus the non-survivors, there were a higher, a statistically  significantly different increase in the number of places where they deviated from the guidelines in the patients who didn't survive than in the patients who did survive.  A little bit indirect evidence, I would say, because maybe they just weren't trying as hard in the patients who were worse off or they didn't think they were going to get back.  There are a lot of potential confounders here, and it's a very small number. But compelling data that would suggest that if you follow the guidelines, you may be able  to do a little bit better. And then looking at survival to discharge, if you just look at the raw data, it looks  like there's a higher percentage of errors in the patients who did not survive to discharge. But this was not statistically significant.  You can see there were a very small number of these patients who survived to discharge, only 20 in this cohort.  So it's likely that this study was underpowered to find the kind of difference that we would expect with this.  But at least it provides some data, the first that I've been able to find anywhere in the literature, that adherence to guidelines potentially does have an impact on outcomes.  So then the question is, if adhering to guidelines improves outcomes, does training improve outcomes?  Can we show that if we train people to learn those guidelines, that we can actually see improvements in survival to discharge and ROSC?  This is a really difficult question to answer in human medicine, which is sort of what we're  relying on to get these answers, because training has been required in Western country for decades and decades and decades.  So everybody who works in a hospital or a health care environment has to have CPR training.  So it's very difficult to find a comparator group, people who haven't been through training, to actually try to answer this question.  But there are local resource differences, and that's one opportunity to maybe think about whether we could try to come up with an answer.  So this was a study that was published back in 2011. It's out of India. And so this was a hospital where there hadn't been advanced life support, basic or advanced  life support training. And they introduced an advanced life support training program that included basic life support.  And so they looked at return of spontaneous circulation and survival to discharge in patients who arrested before the training and patients who arrested after the training.  And you can see they saw statistically significant improvements in both of these things. So ROSC rates went up to 28%.  And among the patients who achieved return of spontaneous circulation, they went from 23% to 69% of those patients surviving to discharge.  So again, relatively small study, single center, but a unique place where they could actually try to answer this question because the training was newly being implemented.  Really difficult to get that data in the United States or Western countries at this point because of standardized training having been around for such a long time.  At the end of the day, though, we know that CPR is a team sport. You can't do CPR effectively on your own, especially not advanced life support.  And so there is this issue of the weakest link on the team when we assess survival to discharge.  Because if you want to say, OK, does training actually make a difference in terms of outcomes, you can't assess individuals.  You have to assess the team performance because you're looking at whether the patient survived to discharge or not. So these are, again, really complex questions to try to answer.  And that's probably why there's not a lot of literature out there really trying to answer these questions because it's just so difficult with the baseline training that's available  and the fact that trying to implement that intervention in a vacuum is really difficult to do these days. So really, really difficult to measure these outcomes.  But at the end of the day, we do have a little bit of data to maybe support it. So if guidelines do matter, if we accept the fact that guidelines matter and that teaching  them matters, then how do we best teach them? And that's really the question I'm going to try to answer to the extent that I'll review  the literature around it about what we can do to sort of maximize these outcomes. So if we think about what would the ideal CPR training look like, how would we design it?  So we would have evidence-based guidelines that we know have an impact on outcome. So that would be step one. It would be thorough, but it would be efficient.  So we don't want to have six days of training because that's really difficult for people to do. But we want to make sure that we get all of the important information across.  So how do we minimize the time that we spend training but still get the effect of that training? It would be replicable and standardized for local implementation.  So that was that third piece of that formula for survival is that local implementation. So it has to be something that you can send out broadly.  If there are only two people who can teach it, it's not going to work. And then you would like, ideally, to have documented efficacy.  So you would like to have improved skills performance, but you'd also want to be able to document better outcomes and show that this training actually leads to more survivals.  And then finally, you want to be able to do it frequently enough that you don't get a huge amount of skill decay.  So we want to know what is the optimal interval at which we have to do retraining in order for people to maintain their skills.  So these are all really important questions, the answers to which we have very little. So unfortunately, there's a lot we don't know about this.  But we'll review the things we do know. So back to the question, does training improve outcomes? So this is a meta-analysis that was just published in 2018.  And the question they asked was, in adult patients who have cardiac arrest, this is a PICO question, so a little review for you.  Does prior participation of one or more members of the resuscitation team in an accredited advanced life support course?  So again, only one person on the team would have to be trained for them to meet criteria here, as opposed to no such participation. So everybody on the team is not trained.  Does that affect these outcomes? So return to spontaneous circulation, survival to discharge, survival to 30 days, and survival to one year.  So that was the question they asked in this meta-analysis. So their initial search found 992 papers, which sounds super exciting, doesn't it?  But then once they reviewed them all, only eight studies met criteria. And you can see there were no randomized controlled trials, which is not surprising, again, because  it's very difficult to figure out how to design a randomized controlled trial like this, where you have this naive population and you train them.  So there were only eight observational studies that were mostly before and after studies that they were able to do.  So this is looking at the outcome of return to spontaneous circulation. And you can see across those studies, they actually found a statistically significant  improvement in outcomes. So you're about 1.6 times as likely to get return to spontaneous circulation in the teams  that had someone who was trained than in the teams that didn't have people that had gone through training. You can see very wide confidence intervals, getting very close to 1.  And if this confidence interval goes down to 1, that means there's no difference between the two. But this was statistically significant.  Looking at survival to discharge, when they looked just straight up at survival to discharge, there was no difference. So you can see the effect size or the odds ratio was 2.  But unfortunately, the confidence intervals were very wide because of the wide range of different types of studies here. So you can see the confidence interval included 1.  So although you could say you're twice as likely to have survival to discharge, it was not statistically significant.  Again, whether that's because this is underpowered or there's really not a difference, we don't know.  And then they did something that I would argue would make me a little suspicious of this, is they decided, OK, well, let's do a different analysis.  So they looked at this risk difference instead. And this was statistically significantly different between the groups.  It's really trying to answer the same question but using a slightly different statistic. And for this particular outcome, it's the only one that they reported this measure in,  which makes me super suspicious. So again, I would say for survival to discharge, I think probably if we had more power in these studies, we might get there.  There's probably an effect. But we don't have that documented at this point. So I would hesitate to call this significant at this point.  Looking at survival to 30 days, there was only one study that looked at this particular outcome. They did show an odds ratio of 7.  So 7 times more likely to survive to 30 days if they were treated by a group where at least one person had training.  But you can see these confidence intervals are very, very, very wide. So go all the way down to 1.6 times as likely. So again, just because it's a small study and just one study.  And then finally, survival to one year, they weren't able to show a difference. And this is, again, down to just two studies, very underpowered. So the overall odds ratio is 3.6.  So 3.6 times as likely to survive to a year. But really, really hugely wide confidence intervals.  What I read here, because I'm an optimist, is maybe it's as much as 120 times as likely to live to one year. But unfortunately, not statistically significant.  So at this point, I would say using this meta-analysis, you could walk away from this and say, OK, yeah.  I think hopefully it does improve outcomes, given all the limitations of these studies. We have some evidence that it improves it. But documenting it is really hard.  And designing these studies in human medicine is really difficult. I think one exciting thing is that designing these studies in veterinary medicine would be a whole lot easier.  Still not easy, but a whole lot easier than in human medicine, because so few of us have standardized CPR training under our belts. So I think we have some opportunities here.  But there were many, many limitations of this meta-analysis. There was a lot of heterogeneity in terms of the number of team members on each team trained and all those things.  And so we have to, I think, interpret this cautiously. But I think it provides some evidence that training matters.  So if we're going to accept that guidelines matter and training matters, then the question becomes, what's the best way to train?  And so I'm just going to review a few of the ill-core meta-analyses, looking at some of the aspects of basic and advanced life support training that we might want to consider as  we think about how we're going to train the people in our practices. So for basic life support, the goals of training would be rapid diagnosis of cardiopulmonary  arrest, how to do chest compressions. If you look at the human literature, ventilation will be a plus or minus for basic life support,  because there are lots of compression-only CPR approaches these days, especially for bystander CPR.  And then in human medicine, automated electric defibrillator training is usually part of basic life support training, because it's so important for out-of-hospital arrests for  bystander CPR. So the questions we're going to look at just quickly here are, what are the best instruction  methods for basic life support training, and what's the optimal interval for retraining, which I think is really key, because if you don't do a lot of CPR every day, your skills  are going to decay quickly. So we really need to have a handle on how often we should be refreshing folks.  So in terms of how best to teach, for basic life support, there's been a fair amount of  work done in human medicine looking at instructor-led versus self-directed training, because a lot  of basic life support training in people is really just learning chest compressions and learning how to turn on and attach an AED, and then the AED does all the work after that.  So they're relatively simple approaches that they're teaching in these courses. So the traditional approach in human medicine has been usually a three- to four-hour course  that is a didactic course taught by an instructor. And then there'll be a hands-on component with a high instructor-to-student ratio, where  they're going to be teaching them the hand skills of how to do chest compressions, potentially how to ventilate, and how to use the AED.  So a three- to four-hour course is sort of typical for the basics of basic life support in human medicine.  This is an approach that was developed through the American Heart Association of... It's called... What is it called? I totally forgot the name of it.  It'll come to me in just a minute. But it's one that is meant to be a completely self-directed training method.  So you get this little inflatable mannequin, you get a DVD with instructional video that lasts about 20 minutes that teaches you how to do chest compressions.  And then it also has information about how to attach an AED. And so they do 24 minutes of this video, and then they have self-guided practice.  They watch the videos, they do the compressions. The mannequin is very simple, but it clicks when you compress far enough. So you get audio feedback when you do the compressions.  So you know whether you're doing them hard enough. And then you follow along on the video to try to get the rate down. So it's a half-hour interaction.  And so they actually did a study comparing these two different approaches. So the C30 is the 30-minute and self-guided video.  And then the HSA AED is the human-guided, the instructor-led training. And if you look at all of the different things they looked at at the end of the training  to try to figure out how well these people knew how to do basic life support, chest compression  rate, tidal volume, number of breaths, mean number of compressions provided each minute, compression depth, and duty cycle.  There was no statistically significant difference between the people who spent four hours in a class and the people who watched the 30-minute video.  So I think this is kind of exciting from the standpoint of some of the basics of basic life support, which you could argue, most important part of CPR, right?  If you don't do good quality chest compressions, all the ALS in the world is not going to make a difference.  So I think this is encouraging that with pretty limited training and with very efficient training, we could have a big impact on people's ability to do basic life support correctly.  So things to think about. I think, obviously, for us, it's a little more complicated because we have different approaches to chest compressions for different animals.  And so I think it will take a little tiny bit more training to get people up to speed. But I think we can be optimistic that with pretty efficient training, we can probably  get the really fundamental concepts of basic life support under folks' belts. So then looking at a meta-analysis that was published as part of the ILCOR 2015 guidelines.  So they asked the question among students who are taking BLS courses in an educational setting, does video or computer self-instruction compare with these traditional instructor-led  courses improve outcomes? So that study that we just looked at was combined with some others.  So there were four randomized controlled trials looking at cognitive knowledge at the end of training.  And if you look at those, when you look across all of them, despite the one I showed you that did show a difference, I'm sorry, take that back.  Looking all of these four together, you have the same basic outcome, which is they didn't  show a difference between instructor-led training and the self-directed training when you pooled across those 370 individuals in those four randomized controlled trials.  When they looked at skill performance at course completion, again, nine randomized controlled trial, one observational study, went over 2,000 individuals.  You can see that the relative risk for being able to do the skills at the end of the course  was one. It's basically the same. A wash between the two different instruction methods. So they seemed equivalent. And then finally, skill performance at one year.  There were two randomized controlled trials that looked at the duration of those skills one year out. And again, you can see no difference between those two.  Unfortunately, you can see the quality metrics for these studies was not great. So low quality or very low quality for all of them.  There were a number of different reasons for that looking at them. But most of them were due to potential risk of bias, either in the way the study was designed  or in the statistical analysis. For some, it was because of the additional feedback that was given to the folks in the  intervention group because they were trying to measure how well they were doing things and they were getting that feedback. So lots of different reasons for that downgrading.  But at least reasonably copious evidence that you can teach basic life support in a pretty efficient way.  So the treatment recommendations that Ilcor made at that point were that video or computer-based  instruction with either synchronous or asynchronous practice is an effective alternative to these more intensive in-person trainings.  Unfortunately, right now, we don't know the impact on actual clinical outcomes because, as you can see, none of these studies actually looked at how they actually did if they were  faced with a real resuscitation. And then the effect of the content of that self-guided learning, really most of these  have looked at, I think it's called CPR Anywhere, this particular course that was put together by the American Heart Association. What other content might do there?  No one really knows. So I think good evidence that we can probably do this pretty efficiently, I think, at the end of the day.  And then in terms of retraining intervals, so you get this initial skill that we have at the time we finish the course, but then we know pretty quickly those skills are going  to decay if we're not using them. So this question asked whether any specific training interval other than 12 to 24 months,  which is the standard right now, would improve skill performance at different time points afterwards.  So again, looking at this meta-analysis, for actual resuscitation skill and survival, nothing.  No one has been able to look at this, and no one knows what the optimal retraining interval is to improve outcomes. So that's step number one.  In terms of cognitive knowledge, there was one randomized controlled trial and one observational study that showed a biweekly video reminder improved self-confidence and willingness  to do CPR, but didn't actually investigate whether they did it correctly. They just were more willing to actually do it, and they said they felt like they could do it better.  So pretty weak evidence there. And then looking at skill performance at one year, there were three randomized controlled  trials and two observational studies, but they were so heterogeneous, they couldn't pull all the data. So they just sort of had to qualitatively look at it.  And sort of looking across those, what they found was that a six-minute monthly practice with biweekly video reminders, so actually getting together once a month to practice  just for six minutes on basic life support skills, but then also every other week getting a little video that just sort of reminded them of those skills, that they were able  to show improved compression depth, not rate, but depth at one year compared to not having those reminders.  But other skills decayed just as quickly as they did without the reminders. So unfortunately, we have very little evidence to base our retraining recommendations on.  We just don't know how frequently and how intensive that training has to be. So the recommendations that ILCOR came up with based on this data, which was very weak,  was that individuals likely to encounter CPR should have frequent retraining, but they don't name what frequent means. So who knows what you should do.  I think you kind of have to decide in your individual practice how often that needs to happen.  And then in terms of knowledge gaps, they said we need more data on this high-frequency, low-volume training.  So that's these little short practices or little short video interventions. They maybe have some promise, but definitely more study is needed in those.  And that we need guidelines to inform that uniform testing and reporting of BLS training can happen. So really, how do we tighten these up and make them more standardized?  So just to summarize for BLS training, the best instruction methods, it seems like self-guided may be useful.  Feedback from an instructor is likely useful, but maybe it can be done in a much more efficient and contained way. But we definitely need a lot more outcome data to know.  And then in terms of retraining interval, we don't know. But it does seem like there's some evidence that more often than just once a year is probably useful.  But we still just don't know how frequent that has to be to prevent that skill decay. So what about advanced life support? We're going to look at three major questions.  So one is mannequin fidelity for advanced life support, leadership and team training, whether that's useful or not, and then timing for retraining, just like we did for basic  life support. So there's this debate that goes on in human medicine in terms of ALS training, especially on high-fidelity versus low-fidelity simulators.  So I'm sure that all of you have used rescue critters mannequins or those sanitary mannequins that are dog shapes, and you do your chest compressions on them.  So we, in veterinary medicine, pretty much have low-fidelity simulators. But in human medicine, they have access to very high-fidelity simulators.  So in human medicine, this would be considered a low-fidelity simulator, very similar to our rescue critters mannequins. You can do chest compressions. You can ventilate.  It's got a little bulb here where you can fake a pulse in it. So pretty simple little mannequin, just like we would use.  And then you could go all the way up to these very fancy high-fidelity simulators in human medicine where you can asculpt them. They have chest rises. They have mechanical pulses.  There are all kinds of fancy things you can do with them. So the question is, does it make a difference in terms of your ability to teach advanced life support?  So this was a study published back in 2011 of 86 medical students that were randomized to either get traditional training, which was a low-fidelity simulator, or a high-fidelity  simulator training. And if you see down here, at initial testing, the high-fidelity group actually got better  scores on their final assessment than the traditional training, the low-fidelity group, with a very significant p-value.  But if you look one year later, skill decay was exactly the same. So without refresher training in between, within a year, everything was exactly the same.  So maybe some initial benefits, but they seemed to go away pretty quickly. Looking at this other study, this was just looking at a high-fidelity versus a low-fidelity mannequin.  They had a series of specific skills that they were checking off on them. And if you look here at their final scores, the number of skills they performed correctly,  there was no difference as to whether it was a high-fidelity or a low-fidelity mannequin. So a little bit conflicting data. Maybe there's a little bit of improvement afterwards.  If you look at these things they were testing on, many of these things were mostly basic life support.  So again, I'm not sure that you could make a great argument for needing a super high-fidelity mannequin for basic life support.  The question is, could it be helpful for advanced life support? So Ilcor did ask this question in the 2015 update to their guidelines.  So they asked whether the use of high-fidelity compared to low-fidelity mannequin changed any of these outcomes, largely the same as the ones we've been talking about.  Definitely more data here. So looking at knowledge at course completion, when they pooled across all of the studies,  which were eight randomized control trials and an observational study, they didn't find any benefit of high-fidelity over low-fidelity for knowledge at course completion.  For skills performance at course completion, so the written test versus actually doing physically what they had to do to be assessed, a larger number of trials.  And they did find a moderate benefit of high-fidelity over low-fidelity for when they're actually  demonstrating these skills and practicing them. Skill performance at course conclusion and at one year, they showed no difference here in this randomized control trial.  And then skill performance at one year in the separate randomized control trial, again, no benefit.  So these were different enough that they had to separate them out in their meta-analysis, and they were relatively small groups.  So maybe a benefit of high-fidelity here for the ALS training, again, evidence not super strong.  So the ill core recommendation is high-fidelity mannequins should be used if the infrastructure is available to support it.  But low-fidelity mannequins are acceptable because the evidence is pretty weak. And then the knowledge gaps, they really felt that there needed to be more research into this area.  So what do we have to do to optimize the use of the high-fidelity simulators? And how do we assess their impact on outcomes?  Leadership and team training is something that people have spent a lot of time on in human medicine trying to figure out whether this actually impacts outcomes.  And so ill core did ask a question about this one. Does the inclusion of specific leadership or team training improve outcome compared to none of that training?  There were a number of trials here that they were able to find. Looking at patient survival, there were two observational studies that showed improved  survival if at least some of the members of the team had team or leadership training. Skill performance and an actual resuscitation, just a small number of trials, but they didn't  find any effect there. Looking at skill performance in people who had gone through with that kind of training  in a more general way, they did find when they were just looking at leadership and teamwork behaviors that it did seem to improve those.  So if they were teaching team skills, they actually were able to see those team skills when they watched actual resuscitations.  And then skill performance at four months to one year, it seemed, again, like teamwork and leadership behaviors were improved even a year after the course was done.  But how that correlates to outcomes, nobody really knows. So their recommendation were that you should include team and leadership training, I think,  largely based on these studies looking at patient survivals being improved by that. And knowledge gap, as with everything else, need more studies.  So really need to get better outcome data here. But it does look like teaching people some of these communication skills can really help with CPRs.  And then retraining, same basic question as for basic life support, should we do retraining more often than every one to two years?  Skill performance at one year, there were four randomized controlled trial. And they found that there was some benefit from these little boosters that happened seven  to nine months after the initial training, that periodic e-learning did improve performance in mock arrests. This was not an actual arrest.  And then there was some low-fidelity mannequin simulations that were sort of built in. And they found, again, there was a benefit in terms of their skill performance in a simulation  setting. And then looking at knowledge, just strictly at knowledge at a year, there was no effect on knowledge. So people seem to be able to remember the knowledge.  It seems like it's more the implementing and actually doing the skills that maybe decays a little bit faster.  So their ultimate recommendations were there should be more frequent than yearly mannequin-based refresher training.  Again, that optimal time for training, nobody really knows. So it could be six months. It could be three months. We just don't know.  So to summarize, mannequin fidelity for ALS training, low-fidelity is probably OK. And it's mostly what we have available.  High-fidelity might be more engaging and maybe could give you some short-term benefits. But it probably isn't essential, which is good, because we don't have a lot of access  to high-fidelity mannequins in veterinary medicine.  We should still be able to do really powerful ALS training. Leadership and team training does seem to be important. CPR is a team sport.  And it's probably a good idea to start to incorporate some of that. The Recover Basic Life Support Training has a module on team skills and team communication  and leadership, which I think hopefully could have some benefit there. Time for retraining is probably important. But we don't know what that is.  And so the recommendation would be to try to do at least some CPR drills a few times a year to try to keep people's minds refreshed about how to do these things.  But unfortunately, we don't have strong evidence to base specific retraining intervals on. OK.  I just wanted to quickly go through the Recover CPR training, which hopefully you guys are familiar with. So the guidelines are open access. You can download them anytime.  We have those online certification courses, the in-person rescuer courses, and then recertification, which is set up for every two years.  The online certification is available through the Recover website. So basic life support, it's a pretty big course.  And this is one of those things that we probably need to tighten up a bit, especially based on the evidence that we have.  There's some cardiorespiratory physiology, diagnosis of cardiopulmonary arrest, how to do compressions, how to ventilate, and that team dynamics module.  And then for advanced life support, initiating advanced life support and some stuff about  vascular access and open chest, treating non-shockable rhythms and treating shockable rhythms. The in-person certification has been around for a few years now.  There's a two-hour basic life support and then a four-hour advanced life support, which is scenario-based, which can be done with either high or low-fidelity mannequins, but  goes through a series of scenarios, and then ultimately a group megacode assessment. So we have tried to tighten that up. And I think it's a good experience.  We've gotten good feedback on that. And that's available at a lot of conferences and things like that for folks.  And hopefully you guys will all someday go out and want to teach this stuff, which would be great. The recertification right now, we require every two years.  There's a one-hour BLS online and a one-and-a-half-hour ALS online course, so very abbreviated, but meant just to refresh.  Q2 years may not be enough, but at least we're getting some folks refreshed with that. And then the instructor certification, we do have a small group of certified CPR instructors  through the Recover Initiative, and those are folks who go out and train these in-person certifications.  So in that course, we cover basic concepts of simulation, how to run it, how to debrief a simulation.  We practice teaching and assessing the different aspects of the course and the specifics of running the simulator that you can use to do these.  And again, that can be a simple software-based simulator, or it can be a full, relatively high-fidelity mannequin. We go to 10.15. Is that right? OK, good. We're on time.  I've lost track. So then the last question I just want to sort of finish with is, do we have evidence that the recovery guidelines have affected the practice of veterinary CPR?  So Manu and his group at Melbourne have done a follow-up to that initial study that I talked about in the previous lecture, where we sort of got our initial ideas that we were maybe  not doing CPR so well in veterinary medicine. And so this is, I'm just going to present some of the data that they collected from that study.  Looking at the, this is, again, the survey went out in 2018 and is being published now. So when asked if people had heard of the Recover Initiative, we were excited that all of the  board-certified folks and all of the residents had. Yay for us. That's great. A lot of the emergency practitioners had as well. About 75% of them had heard of Recover.  Looking at general practitioners, though, we still haven't quite reached them. So there's a whole lot of people in general practice who don't know that there are actually  evidence-based CPR guidelines out there. And that's something I think we all have to work on to try to get the word out. I say this all the time.  I'm probably preaching the converted here. But as people who are hopefully going to go out there and be teaching some of these folks  in general practice, I think they're the ones who have the best chance at having successful  CPRs, because they're the ones who are going to see the acute reversible arrests, the perianesthetic arrests, the ones where we actually have a really good shot.  And so it's disheartening to me that only 35% have even heard that there are guidelines out there for how to do this, because they are the ones, if they jump in quickly, can  probably have really good success rates. So I really hope that you guys will help us with this initiative to get out there and  really get people aware of the fact that we have some evidence about how to do it, and we can actually get really good outcomes with some of these cases.  And then among the people who had heard of the guidelines, so knew that they existed, you can see that the vast majority of them had consulted them.  So some had heard of them, but never read them or never looked at them. The residents, I don't know what's going on here.  I think you guys got to get your act together and get up to 100% with the specialists. But you can see over 90% of the emergency docs and almost 80% of the general practitioners  who had heard of RECOVER had actually consulted the guidelines and adjusted their practice based on what they saw.  So I think that's encouraging that getting the word out can make a difference. We just need to get more word out. So back to that question of how fast to do chest compressions.  This is the post data, the data from the new study.  And you can see, looking at these proportions, among all of the groups, we're definitely better in terms of doing chest compressions at what we currently recommend is the correct  rate. But again, unfortunately, among general practitioners who responded to this survey, about 30% know how fast they're supposed to do chest compressions.  And these are people who bothered to respond to a survey about CPR, which would mean they're probably more likely to have some experience with it.  So I think we still have a lot of work to do, even with the ER docs, who do primarily ER, to really get these basic guidelines out there.  So looking, though, at the effect it had for the board-certified specialists, we went from 13% to 32%-- wait, no, I have this backwards. These are the general practitioners, sorry.  Went from 13% to 32%, the ER docs from 22% to 56%, and the board-certified specialists from 38% to 74%. So again, we have a biased population.  We have people who are responding to a survey about CPR. They're going to be more likely to be somewhat knowledgeable about it and knowledgeable about the guidelines.  But it's at least encouraging that maybe we're making a little progress. What about in cats?  So we know that in cats, based on mostly neonatal pig research for animals that are about the same size as a cat, that we still recommend the same compression rate, 100 to 120 per  minute in cats as we do in dogs. So looking at the data, our hope was that it would be better than it is.  So you can see that even among board-certified specialists, people still want to go faster in cats because they're smaller, and their heart rates, their resting heart rates, are  faster. So this is one of those areas where we probably aren't making as good progress in getting the nuances of how to do basic life support out there.  So Grumpy Cat is not happy about the fact that we're not keeping up with our cat recommendations.  So again, I think lots of opportunity for improvement here in terms of our ability to get that information out.  And then looking at the perception of CPR, Manu mentioned some of this data from the original survey in his talk.  But looking at the proportions of respondents in each of these categories, people who do  CPR more than 10 times a year, you can see a lot of board-certified specialists and residents are doing, at least once a month, are likely doing CPR.  When you get down to the general practitioners, much less frequently. But they're doing it, and it would be great if they were doing it more according to the  guidelines and improving those outcomes, hopefully doing that. Looking at those, again, who do it greater than six times per year but less than 10 times  per year, you can see, again, general practitioners aren't doing it as often, but they're doing it. So we want to get those guidelines out there.  And then asking for their perceptions, is CPR an essential skill? Even among the general practitioners, it's pretty high that people really do think that  veterinarians should know how to do this. So I think there's buy-in with the concept that you should know how to do CPR.  The important thing we need to do is get that training out there for them. And then asking people, what do they feel in terms of their confidence with their own CPR skills?  Board-certified specialists, we're a pretty confident bunch. So even if we're wrong about how to do it, we're very confident that we know what we're doing.  Residents are feeling less confident, even though they're probably a little better at it. Emergency docs, again, not super confident.  But look at the general practitioners, a real significant lack of confidence. And this is really mirrored with what I find when I speak about CPR at some of the larger meetings.  I definitely have people coming up to me saying they don't even try because they're just scared. They don't know how to do it.  And so they don't attempt it when, in fact, they probably could do a really good job and could probably have pretty good success rates.  So I think we have a lot of work to do to get the word out about the fact that we have guidelines.  And then looking at how frequently people are getting trained, I think this is encouraging  to me that there are a relatively large percentage of specialists and residents who have had training within the last six months, which I think is great.  But you can see among the general practitioners, lots of people have never had CPR training at all, which is a little scary.  And then, again, a large number who haven't had it in several years. So I think, again, trying to get that word out there and increasing opportunities for  people to get training will be really helpful. And then also from a newspaper, looking at factors that might affect compliance in basic life support and advanced life support.  So asking them how they do basic and advanced life support and looking at their overall compliance with the guidelines.  In a statistical model, a multivariate model, they looked at the effect of the year of the response.  So whether this was from 2008 or 2017, the professional group, whether they were board certified or emergency practitioners, gender, age, country of practice, and the number  of times they did CPR per year. Really the only two variables that had an impact on their compliance, how likely they were to do it, was whether they were asked in 2017 or 2008.  So they were 3.7 times as likely to do BLS compliant with the guidelines in 2017 than in 2008, which I think is exciting.  And then whether they were board certified or emergency docs. So the board certified folks were twice as likely to be BLS compliant than the emergency doctors.  And then same for ALS, same basic idea, about 1.8 times as likely if you were asking people now than in 2008 to be compliant with ALS guidelines.  And then 2.3 times as likely to be compliant if you were board certified than if you were an emergency doctor.  So again, I think it's encouraging to see that things seem to be changing. Again, we have to take this with a grain of salt. This is a convenient sample.  Probably a little bit of a biased sample would get ranked down a little bit on those quality ratings if we use the grade approach to rank it.  But I think at least provides us some foundation to think that maybe we can be making a difference here.  So just to summarize, we have a lot of work to do in terms of how we do veterinary CPR  training, trying to expand our reach a little bit more, and trying to figure out these retraining questions.  I think we have decent evidence that awareness of the guidelines actually improves compliance with the guidelines. So if you know they exist, you're more likely to do them.  So even just raising awareness might have an impact. And I think it's safe to say that things are getting better.

Video Summary

The video titled "Train and Vein: The Impact of Guidelines and Training on CPR Outcomes" discusses the importance of proper CPR training and the impact it has on patient outcomes. The presenter discusses the epidemiology of cardiopulmonary arrest and the low survival rates associated with it. The video also highlights the need for guidelines and training to improve CPR outcomes and the best way to provide effective training. There is evidence that following guidelines and adhering to proper training can improve outcomes, although the data is limited. The video discusses various studies that have looked at different aspects of CPR training, such as mannequin fidelity, leadership and team training, and retraining intervals. The evidence suggests that self-guided training may be effective and that more frequent retraining may be necessary. The presenter also discusses the Recover CPR training program and the need to increase awareness of the guidelines among veterinary professionals. Overall, the video emphasizes the importance of proper CPR training and the need to continue to improve training methods to improve patient outcomes.

Asset Subtitle

Professional Development and Education, Cardiovascular, 2020

Asset Caption

This is a presentation from the 2020 Critical Care Congress precourse, Cardiopulmonary Resuscitation, Electrolyte, and Acid-Base Disorders for the Veterinary Emergency and Critical Care Specialist. Train in Vain? Evidence for the Impact of Guidelines and Training on CPR Outcomes was presented by Daniel Fletcher, PhD, DVM, DACVECC.

The course covered topics including updates from research, electrolyte disorders commonly and less commonly seen in the critical care setting, importance of chloride and its role in resuscitation management and the kidney, and acid-base disorders, including physiology, blood gas interpretation, and treatment.

Meta Tag

Content Type Presentation

Knowledge Area Professional Development and Education

Knowledge Area Cardiovascular

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Veterinary Medicine

Tag Cardiac Arrest

Year 2020

Keywords

CPR training

patient outcomes

guidelines

training impact

cardiopulmonary arrest

mannequin fidelity

leadership and team training

retraining intervals

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