Which factors predict candidate outcome in advanced life support courses? A preliminary observational study

PURPOSE: To identify factors associated with candidate outcome in the European Resuscitation Council (ERC) advanced life support (ALS) provider courses. METHODS: Medical doctors participating as candidates to consecutive ALS courses organised by an ERC training centre in Italy were enrolled in this prospective cohort study. The association between the ALS course outcome and candidate demographics, professional background and pre-course knowledge measured by using the pre-course multiple choice quiz (MCQ) was investigated by using logistic regression. RESULTS: A total of 283 candidates, median age 31 years, were evaluated. Among them, 269 (95.1%) passed the final evaluation and 14 (4.9%) failed. Candidates who passed were younger (median age 31 vs. 37.5 years; p = 0.006) and attained a higher pre-course MCQ score (median 84 vs. 72.5%; p < 0.0001). On multivariate analysis, a higher pre-course MCQ score (OR 1.18 [95%CI 1.09-1.28]) and a basic life support (BLS) certification (OR 5.00 [95%CI 1.12-22.42]) were independent predictors of candidate success, while older age was associated with a significantly higher risk of failing (OR 0.90 [95%CI 0.83-0.97]). Female candidates had higher pass rates (97.2 vs. 91.2%; p = 0.048); however, after correction for confounders gender was not significantly associated with candidate outcome. Neither candidate specialty nor site of work was a predictor of candidate success. CONCLUSIONS: On ALS courses, younger age and a higher level of specific pre-course knowledge, as measured by both the pre-course MCQ and the presence of BLS certification, are the most important predictors of success. Candidate gender and professional background did not show a significant correlation with course outcom

Levosimendan for the prevention of acute organ dysfunction in sepsis

BACKGROUND Levosimendan is a calcium-sensitizing drug with inotropic and other properties that may improve outcomes in patients with sepsis. METHODS We conducted a double-blind, randomized clinical trial to investigate whether levosimendan reduces the severity of organ dysfunction in adults with sepsis. Patients were randomly assigned to receive a blinded infusion of levosimendan (at a dose of 0.05 to 0.2 μg per kilogram of body weight per minute) for 24 hours or placebo in addition to standard care. The primary outcome was the mean daily Sequential Organ Failure Assessment (SOFA) score in the intensive care unit up to day 28 (scores for each of five systems range from 0 to 4, with higher scores indicating more severe dysfunction; maximum score, 20). Secondary outcomes included 28-day mortality, time to weaning from mechanical ventilation, and adverse events. RESULTS The trial recruited 516 patients; 259 were assigned to receive levosimendan and 257 to receive placebo. There was no significant difference in the mean (±SD) SOFA score between the levosimendan group and the placebo group (6.68±3.96 vs. 6.06±3.89; mean difference, 0.61; 95% confidence interval [CI], −0.07 to 1.29; P=0.053). Mortality at 28 days was 34.5% in the levosimendan group and 30.9% in the placebo group (absolute difference, 3.6 percentage points; 95% CI, −4.5 to 11.7; P=0.43). Among patients requiring ventilation at baseline, those in the levosimendan group were less likely than those in the placebo group to be successfully weaned from mechanical ventilation over the period of 28 days (hazard ratio, 0.77; 95% CI, 0.60 to 0.97; P=0.03). More patients in the levosimendan group than in the placebo group had supraventricular tachyarrhythmia (3.1% vs. 0.4%; absolute difference, 2.7 percentage points; 95% CI, 0.1 to 5.3; P=0.04). CONCLUSIONS The addition of levosimendan to standard treatment in adults with sepsis was not associated with less severe organ dysfunction or lower mortality. Levosimendan was associated with a lower likelihood of successful weaning from mechanical ventilation and a higher risk of supraventricular tachyarrhythmia. (Funded by the NIHR Efficacy and Mechanism Evaluation Programme and others; LeoPARDS Current Controlled Trials number, ISRCTN12776039.

Autopsy as an outcome and performance measure: three years of hospital autopsy as an instrument of clinical audit

An extensive literature documents a high prevalence of errors in clinical diagnosis discovered at autopsy. Multiple studies have suggested no significant decrease in these errors over time. Despite these findings, autopsies have dramatically decreased in frequency in the United States and many other countries. In 1994, the last year for which national U.S. data exist, the autopsy rate for all non-forensic deaths fell below 6%. The marked decline in autopsy rates from previous rates of 40\u201350% undoubtedly reflects various factors, including reimbursement issues, the attitudes of clinicians regarding the utility of autopsies in the setting of other diagnostic advances, and general unfamiliarity with the autopsy and techniques for requesting it, especially among physicians-in-training. The autopsy is valuable for its role in undergraduate and graduate medical education, the identification and characterization of new diseases, and contributions to the understanding of disease pathogenesis. Although extensive, these benefits are difficult to quantify. This review of the last three years of hospital autopsy in Lucca studied the more easily quantifiable benefits of the autopsy as a tool in performance measurement and improvement. Such benefits largely relate to the role of the autopsy in detecting errors in clinical diagnosis and unsuspected complications of treatment. It is hoped that characterizing the extent to which the autopsy provides data relevant to clinical performance measurement and improvement will help inform strategies for preserving the benefits of routinely obtained autopsies and for considering its wider use as an instrument for quality improvement

Interviewer-driven Variability in Social Network Reporting: Results from Health and Aging in Africa: a Longitudinal Study of an INDEPTH community (HAALSI) in South Africa

Social network analysis depends on how social ties to others are elicited during interviews, a process easily affected by respondent and interviewer behaviors. We investigate how the number of self-reported important social contacts varied within a single data collection round. Our data come from Health and Aging in Africa: a Longitudinal Study of an INDEPTH community (HAALSI), a comprehensive population-based survey of individuals aged 40 years and older conducted over 13 months at the Agincourt health and demographic surveillance site in rural South Africa. As part of HAALSI, interviewers elicited detailed egocentric network data. The average number of contacts reported by the 5,059 respondents both varied significantly across interviewers and fell over time as the data collection progressed, even after adjusting for respondent, interviewer, and respondent–interviewer dyad characteristics. Contact numbers rose substantially after a targeted interviewer intervention. We conclude that checking (and adjusting) for interviewer effects, even within one data collection round, is critical to valid and reliable social network analysis. Measurements of social networks depend on the number and type of social ties to others (Berkman et al. 2000; Smith and Christakis 2008). These ties are typically elicited through interviews, a process easily affected by respondent or interviewer characteristics and behaviors. Understanding social network structure and composition requires substantial amounts of information from respondents (“egos”) about the people (“alters”) they have relationships with (Marsden 1990). Notably, the survey burden associated with network data collection depends heavily on the number of alters elicited through “name generator” questions: Each alter named leads to the repetition of all follow-up questions characterizing the ego–alter relationship (“name interpreters”; Burt 1984). Interviewers have been identified as a key source of variation in survey responses, particularly for questions that are attitudinal, ambiguous, or have complex skip patterns (West and Blom 2016). Several studies have previously identified interviewer effects on network size (Brüderl et al. 2013; Josten and Trappmann 2016; Marsden 2003; Paik and Sanchagrin 2013; van Tilburg 1998). These interviewer effects may arise from differential understanding of survey questions, and therefore how questions are presented to respondents. Interviewers can also affect which alters are elicited due to their own characteristics (e.g., sex, race, age, or experience), or the nature of the interviewer–respondent dyad (e.g., gender, race, or age homophily), leading to different lines of enquiry, levels of probing, or expectations of social acceptability (Collins 1980; Hox 1994; Marsden 2003; Phung et al. 2015). Furthermore, if respondents or interviewers are aware that naming more alters substantially increases survey length, then either group may consciously or unconsciously seek to minimize the number of alters named (Eagle and Proeschold-Bell 2015; van der Zouwen and van Tilburg 2001). In cross-sectional surveys, the opportunities for respondents to learn are limited, but those for interviewers will increase as the survey period progresses. Interviewers may try to reduce survey burden, either for themselves or for respondents, by favoring language or probes that decrease the number of alters elicited. Indeed, past studies in Europe have found evidence of interviewers intentionally filtering out questions by entering fewer responses that would trigger more questions. Such filtering behavior has been seen in Europe for interviewers who are being compensated by the interview rather than by the hour (Josten and Trappmann 2016; Kosyakova et al. 2014), for interviewers with prior experience using the relevant screening tool (Matschinger et al. 2005), and where interviewers are under substantial pressure to complete more interviews (Schnell and Kreuter 2000). We aim to extend this literature by assessing how the number of alters elicited systematically changed over the course of a cross-sectional social network survey of older adults in rural South Africa. We show a substantial drop in alter numbers over time, and a swift reversal following retraining, providing substantial evidence for interviewer effects

Mechanical versus manual chest compressions in the treatment of in-hospital cardiac arrest patients in a non-shockable rhythm : a randomised controlled feasibility trial (COMPRESS-RCT)

Background Mechanical chest compression devices consistently deliver high-quality chest compressions. Small very low-quality studies suggest mechanical devices may be effective as an alternative to manual chest compressions in the treatment of adult in-hospital cardiac arrest patients. The aim of this feasibility trial is to assess the feasibility of conducting an effectiveness trial in this patient population. Methods COMPRESS-RCT is a multi-centre parallel group feasibility randomised controlled trial, designed to assess the feasibility of undertaking an effectiveness to compare the effect of mechanical chest compressions with manual chest compressions on 30-day survival following in-hospital cardiac arrest. Over approximately two years, 330 adult patients who sustain an in-hospital cardiac arrest and are in a non-shockable rhythm will be randomised in a 3:1 ratio to receive ongoing treatment with a mechanical chest compression device (LUCAS 2/3, Jolife AB/Stryker, Lund, Sweden) or continued manual chest compressions. It is intended that recruitment will occur on a 24/7 basis by the clinical cardiac arrest team. The primary study outcome is the proportion of eligible participants randomised in the study during site operational recruitment hours. Participants will be enrolled using a model of deferred consent, with consent for follow-up sought from patients or their consultee in those that survive the cardiac arrest event. The trial will have an embedded qualitative study, in which we will conduct semi-structured interviews with hospital staff to explore facilitators and barriers to study recruitment. Discussion The findings of COMPRESS-RCT will provide important information about the deliverability of an effectiveness trial to evaluate the effect on 30-day mortality of routine use of mechanical chest compression devices in adult in-hospital cardiac arrest patients