SPRING 2012 ISSUE NO 14. Resuscitation Care

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1 SPRING 2012 ISSUE NO 14 CARDIAC FIRST RESPONSE Out-of-Hospital cardiac arrest remains one of the leading causes of death in Europe. In Ireland, it is estimated that approximately 5000 people die each year from sudden cardiac death. Survival from cardiac arrest is known to depend on a number of factors, among them the quality of the CPR provided as well as the validity of the treatment guidelines and a well functioning chain of survival. Contents 1 Cardiac First Response 4 Health Informatics 5 Responder Alert App 6 Pre-hospital Defibrillation 8 Registration Consultation Early Access Early CPR Early Defibrillation Early ALS Early Post Resuscitation Care 9 Clarity on Registration Since the International Liaison Committee on Resuscitation (ILCOR) published their revised guidelines in October 2010, PHECC set about revisiting clinical practice guidelines and the Cardiac First Response Standard to incorporate the changes in basic life support. The result was 2 new CFR courses called CFR Community and CFR Advanced. The work undertaken by Mark Dixon, Academy of Emergency Medical Education, University of Limerick is gratefully acknowledged Statistics 10 Recognised Institutions & Courses 11 CPG-Approved Organisations 12 Out-of-Hospital Cardiac Arrest Register SYSTEM CERTIFICATION ISO 9001 ISO 9001: 2008 Management System 1

2 CFR Online update. To support the roll out of these two courses, PHECC designed an online update course for existing CFR Instructors. Since August, a total of 1424 CFR Instructors successfully registered and completed the online course. For anyone who has yet to complete the update, please login and register with PHECC s Online Academy at CFR Instructor survey. PHECC plans to survey all CFR Instructors in early Instructors who participated in the online update will be invited by , to participate in a survey, to evaluate the quality of the CFR training products and courses. Recognised Institutions. There are now a total of 40 recognised institutions delivering CFR Advanced and or CFR Community courses in Ireland. CFR Training material. A new set of course material was developed to support the delivery of the new CFR courses. This includes a DVD led course, an Instructor Manual and a Student Handbook. These products are available to purchase from recognised institutions (or OFAAA) or can be purchased directly from our website using PayPal. New CFR Community Online course An Bord Altranais Category 1 approval for CFR courses The Irish College of General Practitioners (ICGP) has approved CFR courses for external CPD credits New CFR Community Online course. This online course remains in development and when completed it will be available through participating recognised institutions. The online course has 3 sections theory, knowledge test and simulations. Licensed users/students will access the course on any internet enabled PC and present at a designated recognised institution for assessment and certification. More about this product later in CFR and registered nurses and midwives. Last December, PHECC successfully applied to An Bord Altranais for Category 1 approval with the continuing education units (CEUs) for CFR courses as outlined: Name of course Course grouping Approved from/to Continuing Education Units Cardiac First Response 1 7 December Advanced 7 December 2012 Cardiac First Response 7 December Community 1 7 December 2012 Category 1 approval applies to programmes that support continued professional and practice development for registered nurses and midwives. Recognised Institutions are reminded to promote Category 1 approval and CEUs to current and prospective course participants (nurses and midwives). 2

3 CFR and registered medical practitioners. CFR and registered medical practitioners. In January, PHECC successfully applied to the Irish College of General Practitioners (ICGP) for CPD external credits for 2012 as outlined: Titles Dates of Approval GMS Study Leave External CPD Sessions Approved Credits Approved Cardiac First Response 13/01/ Advanced Cardiac First Response 13/01/ Community Furthermore, due to a process of mutual recognition between the Irish Postgraduate Medical Training Bodies, when any course/meeting or event has been accredited by one of them, then any registered medical practitioner who attends the course can record the CPD credits. Recognised Institutions may wish to inform medical practitioners that CPD credits now apply for both CFR courses. Institutions are reminded to use the ICGP references: * CFR Community * CFR Advanced Institutions are reminded to use the ICGP references: * CFR Community * CFR Advanced CFR and PHECC registered practitioners. PHECC will commence the first 3 year cycle of continuous professional competence (CPC) for practitioners during The full details of CPC will be communicated separately to registrants; however, it is important here to highlight the important role of CFR certification for practitioners going forward. Maintaining CFR Advanced level certification (every 2 years) and participating in CFR refresher training (every other year) will allow registrants to collect 2 compulsory CPC points annually. PHECC is delighted with the progress that CFR is making and is mindful that without the continued support of our recognised institutions that none of this would be possible. It is PHECC s strategy to encourage as many people as possible to train in resuscitation. 3

4 Update from the area of Information (Health Informatics): Ambulatory Care Report (ACR) Further roll-out of eacr is currently being considered in line with PHECC s ICT strategic direction for all electronic patient data collection... The first national report for the collection of minor injury data was implemented by the auxiliary and voluntary organisations in May 2011 at a music event in Slane, Co Meath. Following this event the ACR was rolled out nationally for use by all auxiliary and voluntary organisations. In parallel, a beta version of an electronic ACR (eacr) was developed by Valentia Technologies, the company previously developed the electronic patient care report (epcr). The eacr was developed in the same likeness to the paper ACR and in July 2011, an eacr trial took place at Oxegen music festival in Punchestown, County Kildare. Among the objectives of the trial were: i) feasibility of real-time patient data collection at an event ii) users data entry experience iii) connectivity issues experienced iv) remote troubleshooting solved the problem. The Order of Malta, Civil Defence and Event Medical assisted us in the trial and over 2,900 patient records were captured over the course of the event. Further roll-out of eacr is currently being considered in line with PHECC s ICT strategic direction for all electronic patient data collection but if you have any questions please do not hesitate to Jacqueline@phecc.ie 4

5 Responder Alert Application (RAApp) Phase 1 of this project involved the development of a smartphone responder application prototype which would not be specific to any one operating system and so could be used on any model of smart phone. The on-screen application displays 6 buttons, for example, Time mobile, Time at scene and Time Clear, and each button can be selected by the responder when appropriate. In addition there is a CFR report button and yes or no can be selected to indicated whether the report was completed or not. Phase 2 of the project will facilitate the completion of the CFR report on the RAApp. In addition Incident mapping is being developed where by the route to the incident will be displayed on the phone and the expected time of arrival at the incident location will be displayed. An Alert sound will also be included which will be audible when the phone in silent mode. Approximately 20 practitioners and responders have taken part in phase 1 testing. There is a lot of interest from both practitioners and responders to be involved in the next phase of testing and enquiries have been received from an additional 40 people. You can also become involved in the testing phase of the RAApp; one of the criteria is that you are currently dispatched to an incident via an alert text message from your Command and Control Centre. If you are, and are interested in becoming involved, send an the following address and you will receive the guidelines: gearoid@phecc.ie We plan to pilot the RAApp end March this year. For further RAApp details log on to: phecc%20website.pdf Information Standards In 2011 we published the PHECC Information Standards for the Patient Care Report (PCR), Cardiac First Response (CFR) Report and the Ambulatory Care Report (ACR). Each of the standards consists of the definition of each of the data elements on the reports and clear instruction on how to complete them. The information standards will regulate the data collected, as definitions and elements are primarily the same across all reports and as a result, the same data will be collected by all practitioners /responders in all service providers: statutory, auxiliary, voluntary and private. The collection of patient data provides the building blocks for clinical audit initiatives in the future. Safe delivery of healthcare to the patient relies on access to and the use of accurate, complete, timely and relevant healthcare information which will only be available if the patient data is completed by all practitioners and responders on the relevant reports. The Standards can be accessed when you select the Information Management button on the PHECC web site. For any questions you may have in relation to Informatics or any other area of interest Jacqueline@phecc.ie or info@phecc.ie Examinations During 2011 the Education and Training Standards (2007) were gradually phased out and replaced by the 2011 Standards and as a result the PHECC Examination content at all levels required revision. This was completed with great gusto by all involved and I would like to thank those involved for the dedication and time you gave this huge exercise. Currently all NQEMT examinations are based on the 2011 Education and Training Standards. Information Standards Safe delivery of healthcare to the patient relies on access to and the use of accurate, complete, timely and relevant healthcare information... 5

6 Pre-hospital Defibrillation position paper Defibrillation is a lifesaving intervention for victims of sudden cardiac arrest (SCA). Defibrillation in isolation is unlikely to reverse SCA unless it is integrated into the chain of survival. The chain of survival should not be regarded as a linear process with each link as a separate entity but once commenced with early access the other links, other than post return of spontaneous circulation (ROSC) care, should be operated in parallel subject to the number of people and clinical skills available. Cardiac arrest process Early Access Early CPR Early Defibrillation Early ALS Post ROSC Care ILCOR guidelines 2010 identified that without ongoing CPR, survival with good neurological function from SCA is highly unlikely. Defibrillators in AED mode can take up to 30 seconds between analysing and charging during which time no CPR is typically being performed. The position below is outlined to ensure maximum resuscitation efficiency and safety. Position 1 Defibrillation mode 1.1 Advanced Paramedics, and health care professionals whose scope of practice permits, should use defibrillators in manual mode for all age groups. 1.2 Paramedics may (consider) using defibrillators in manual mode for all age groups. 1.3 EMTs and Responders shall use defibrillators in AED mode for all age groups. 2 Hands off time (time when chest compressions are stopped) 2.1 Minimise hands off time, absolute maximum 10 seconds. 2.2 Rhythm and/or pulse checks in manual mode should take no more than 5 to 10 seconds and CPR should be recommenced immediately. 2.3 When defibrillators are charging CPR should be ongoing and only stopped for the time it takes to press the defibrillation button and recommenced immediately without reference to rhythm or pulse checks. 2.4 It is necessary to stop CPR to enable some AEDs to analyse the rhythm. Unfortunately this time frame is not standard with all AEDs. As soon as the analysing phase is completed and the charging phase has begun CPR should be recommenced. 6

7 3 Energy 3.1 Biphasic defibrillation is the method of choice. 3.2 Biphasic truncated exponential (BTE) waveform energy commencing at 150 to 200 joules shall be used. 3.3 If unsuccessful the energy on second and subsequent shocks shall be as per manufacturer of defibrillator instructions. 3.4 Monophasic defibrillators currently in use, although not as effective as biphasic defibrillators, may continue to be used until they reach the end of their lifespan. 4 Safety 4.1 For the short number of seconds while a patient is being defibrillated no person should be in contact with the patient. 4.2 The person pressing the defibrillation button is responsible for defibrillation safety. 4.3 Defibrillation pads should be used as opposed to defibrillation paddles for pre-hospital defibrillation. 5 Defibrillation pad placement 6 Paediatric defibrillation 6.1 Paediatric defibrillation refers to patients less than 8 years of age. 6.2 Manual defibrillator energy shall commence and continue with 4 joules/kg. 6.3 AEDs should use paediatric energy attenuator systems. 6.4 If a paediatric energy attenuator system is not available an adult AED may be used. 6.5 It is extremely unlikely to ever have to defibrillate a child less than 1 year old. Nevertheless, if this were to occur the approach would be the same as for a child over the age of 1. The only likely difference being, the need to place the defibrillation pads anterior and posterior, because of the infant s small size. 7 Implantable Cardioverter Defibrillator (ICD) 7.1 If an Implantable Cardio-verter Defibrillator (ICD) is fitted in the patient, treat as per CPG. It is safe to touch a patient with an ICD fitted even if it is firing. 5.1 The right defibrillation pad should be placed mid clavicular directly under the right clavicle. 5.2 The left defibrillation pad should be placed mid-axillary with the top border directly under the left nipple. 5.3 If a pacemaker or Implantable Cardio-verter Defibrillator (ICD) is fitted, defibrillator pads should be place at least 8 cm away from these devices. This may result in anterior and posterior pad placement which is acceptable. 7

8 Registration Consultation - Your Response All new PINs issued from January 2012 will be in 6-digit format. Do you agree with this proposal? Answer Options Response Percent Response Count Yes 82.1% 540 No 17.9% 118 Comments/Suggestions 85 Answered question 658 Some Comments Can you use letters as well as numbers in the pin number? It would be easier to remember. I suppose this is to allow for more people to join the register. I cannot understand why this change needs to be made. Issue PHECC ID Card Holders with ID? PHECC propose to annualise registration dates at each level on the register. Do you agree with annual renewal dates? Answer Options Response Percent Response Count Yes 77.4% 509 No 22.6% 149 Comments/Suggestions 105 Answered question 658 Some Comments Renewal dates should depend on your registration date. Is this a revenue generating exercise? Why not every two years or even five? No direct impact on individuals. Field Guide Smart Phone Application - Consultation We want practitioners help to develop this project. Please go to Suggested annual renewal dates are: EMT - July Paramedic - April Advanced Paramedic - September Do you agree with the proposed renewal dates? Answer Options Response Percent Response Count Yes 82.5% No 17.5% Comments/Suggestions 88 Answered question 633 Some Comments Fine with P and AP. July not a good month due to holidays and leave. It is quite possibly a practitioner could miss their date of renewal. Why not January for EMT? Seems to make sense to separate to spread the admin load. Believe better to be Jan-Dec and re-register in jan. Online registration is being introduced in 2012 to improve efficiencies in the registration process. This online system will enable existing registrants to update their own information directly. Do you agree with this initiative? Answer Options Response Percent Response Count Yes 94.5% 598 No 5.5% 35 Comments/Suggestions 82 Answered question 633 Some Comments As long as there is security to prevent someone updating my details with just my pin. This is good as it falls into line with other organisations / companies. But reminders will need to be sent. Online is the way to go in the age of smartphones 8

9 Assessment of Equivalence of Professional Qualifications - New Applications in 2011 UK 9 Poland 7 USA 6 Denmark 2 Australia 1 Austria 1 Czech Republic 1 South Africa 1 CLARITY ON REGISTRATION It is mandatory to be registered to practice. It is not mandatory to be registered to be employed. It is a matter for the employer to ensure only registered practitioners practice. If a CPG approved organisation knowingly allowed an unregistered person to practice at the clinical level of practitioner (EMT, P or AP), its CPG approval could be withdrawn by PHECC. NQEMT Exam Statistics 2011 EMT PARAMEDIC ADVANCED PARAMEDIC 9

10 PHECC-RECOGNISED TRAINING INSTITUTIONS & APPROVED COURSES 10

11 CPG-APPROVED ORGANISATIONS CPG-APPROVED ORGANISATIONS 11

12 OHCAR goes National Just-released data from the Out-of-Hospital Cardiac Arrest Register (OHCAR) shows that more than 5% of a total of 1700 patients survived to hospital discharge. Up to now it was thought that OHCA survival was as low as 1%. Approximately half of ALL patients received bystander CPR and almost half of all surviving patients received CPR. It is clear that if we can further increase bystander CPR, we can also increase the chances of survival. Recent studies in Sweden attributed their improved survival rate to increased bystander CPR. Nationwide introduction of dispatch-assisted CPR and PHECC s Citizen CPR programme will hopefully mean that we will see a similar effect in Ireland. Additionally, the dedication shown by First Responders in maintaining the resuscitation attempt until EMS arrival should not be understated. OHCAR has also shown the vital role that General Practitioners play in cardiac arrest management, from resuscitation to the administration of life-saving drugs. Additionally, staff in community residential units have been part of successful resuscitation attempts. OHCAR has demonstrated that there is a willingness among the public, the voluntary, auxiliary and statutory emergency services to work together to provide appropriate and timely pre-hospital resuscitation. At present, approximately one in twenty people in Ireland who arrest in the community will survive following a resuscitation attempt. There is room for improvement and gathering data is a vital step in achieving this. The national implementation of OHCAR embeds an...additionally, the dedication shown by First Responders in maintaining the resuscitation attempt until EMS arrival should not be understated. A fast and appropriate ambulance service response is key in determining patient survival in almost all cases. Since the beginning of 2012, the OHCAR has been receiving data nationally, a critical element in establishing a reliable database on OHCA response and management for Ireland. A fast and appropriate ambulance service response is key in determining patient survival in almost all cases. Indeed the skill and expertise of ambulance personnel is evident in OHCAR data. First Responders have managed to fully resuscitate patients in a number of cases and their ability to perform CPR and defibrillation when necessary are evident in the OHCAR data. important tool for measuring and describing the Irish response to out-of-hospital cardiac arrest. OHCAR is in the process of being integrated into the National Ambulance Service. It is a testament to the cooperation and work of those involved that this PHECC-led project is now to become part of mainstream services. OHCAR is run in co-operation with the National Ambulance Service, Pre-Hospital Care Council (PHECC), Discipline of General Practice & Primary Care, NUI Galway and the Public Health department in the North West. Abbey Moat House, Abbey Street, Naas, County Kildare, Ireland. Phone: (0) Fax: (0) info@phecc.ie Web: 12