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Perceived challenges during resuscitation of in-hospital cardiac arrests in the COVID-19 era

  • Lene Holst Andersen
    Affiliations
    Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
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  • Bo Løfgren
    Affiliations
    Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
    Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
    Institute of Clinical Medicine, Aarhus University, Denmark
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  • Kristian Krogh
    Affiliations
    Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
    Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark
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  • Vinay Nadkarni
    Affiliations
    Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, United States
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  • Kasper Glerup Lauridsen
    Correspondence
    Corresponding author at: Emergency Department, Randers Regional Hospital, Skovlyvej 15, 8930 Randers NE, Denmark.
    Affiliations
    Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
    Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, United States
    Emergency Department, Randers Regional Hospital, Randers, Denmark
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      To the Editor,
      COVID-19 is a challenge for in-hospital cardiopulmonary resuscitation (CPR).
      • Girotra S.
      • Tang Y.
      • Chan P.S.
      • Nallamothu B.K.
      Survival After In-Hospital Cardiac Arrest in Critically Ill Patients.
      A meta-analysis showed increased 30-day mortality of in-hospital cardiac arrest (IHCA) cases with COVID-19 compared to non-COVID-19 patients.
      • Ippolito M.
      • Catalisano G.
      • Marino C.
      • et al.
      Mortality after in-hospital cardiac arrest in patients with COVID-19: A systematic review and meta-analysis.
      Several studies have raised concerns about challenges due to donning personal protective equipment (PPE),
      • Girotra S.
      • Tang Y.
      • Chan P.S.
      • Nallamothu B.K.
      Survival After In-Hospital Cardiac Arrest in Critically Ill Patients.
      • Hayek S.S.
      • Brenner S.K.
      • Azam T.U.
      • et al.
      In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study.
      but these challenges are speculated, and real challenges perceived during real resuscitation attempts are unknown. We report the first data on the challenges experienced by cardiac arrest team members during IHCA resuscitation of isolated/COVID-19-patients.
      We performed a post-hoc analysis of a prospective multicenter clinical study identifying barriers and facilitators perceived by designated cardiac arrest team members during IHCA across 6 Danish hospitals.
      • Lauridsen K.G.
      • Krogh K.
      • Müller S.D.
      • et al.
      Barriers and facilitators for in-hospital resuscitation: A prospective clinical study.
      In brief, we used an immediate after-event, asynchronous survey of individual cardiac arrest team members following 924 resuscitation attempts (Oct 2016–Jan 2021). We collected a total of 3698 survey responses, including 2095 narrative comments on CPR quality, teamwork, and communication. As the initial analysis revealed barriers related to PPE, we conducted a post-hoc deductive selection of all responses related to isolated/COVID-19-patients, followed by an inductive thematic analysis.
      We identified 25 survey responses from cardiac arrest team members from 24 IHCA resuscitation attempts relating to isolation/COVID-19. Thematic analysis revealed 4 isolation/COVID19 related themes: delay of treatment, communication, teamwork and “other” (Table 1). Delay of treatment was due to procuring or donning PPE or if medication and equipment were placed outside the patients’ room. Communication was related to challenges of hearing and understanding each other when wearing PPE and team members being divided into separate rooms. Teamwork challenges included too few resuscitation personnel in the patient room and the inability to identify individual team members and their roles due to PPE. Other comments included team members not being aware of the isolated status of the patient.
      Table 1Themes specific to isolation/COVID-19 events.
      Number of responsesSubthemeBarriers
      8Delay of treatmentProcuring and donning PPE

      Medication/equipment outside of the patient room

      Altered placement of equipment due to isolation/new premises
      9CommunicationTeam divided with some members outside of the patient room

      PPE, especially masks
      9TeamworkNot being able to identify the roles of team members

      Too few people
      4OtherNot identifying the patient as COVID-19-risk patient
      PPE: Personal Protective Equipment.
      The 4 major themes relating to isolated/COVID-19 patients are a subset of the 24 themes identified in the overall cohort of 924 resuscitation attempts previously reported: loud and clear speech, role allocation, crowd control, and arrival time of team members. Specifically, isolation/COVID-19 posed a unique challenge as crowd control relates to lack of hands as opposed to over-crowding.
      • Nallamothu B.K.
      • Guetterman T.C.
      • Harrod M.
      • et al.
      How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed?.
      Our findings exemplify the importance of continual organizational evaluation and highlights the need for contextualized in-situ training.
      • Youssef F.A.
      • Patel M.
      • Park H.
      • Patel J.V.
      • Leo J.
      • Tanios M.A.
      Protected code blue: using in situ simulation to develop a protected code blue and modify staff training protocol—experience in a large community teaching hospital during the COVID-19 pandemic.
      • Daly Guris R.J.
      • Doshi A.
      • Boyer D.L.
      • et al.
      Just-in-Time Simulation to Guide Workflow Design for Coronavirus Disease 2019 Difficult Airway Management.
      • Daly Guris R.J.
      • Elliott E.M.
      • Doshi A.
      • et al.
      Systems-focused simulation to prepare for COVID-19 intraoperative emergencies.
      Simulation can be used to improve teamwork and compliance of donning PPE rapidly, and enhancing communication while wearing PPE with team members being separated in different rooms. Additionally, our findings reveal important organizational decisions that might include: Who should wear PPE? Who should support PPE donning team members? Should sstickers be used to identify team members’ roles while wearing PPE? Does the placement of important resuscitation equipment need to be changed?
      Notably, this study is limited by its reliance on subjective comments. The quantitative impact of isolation/COVID-19 on CPR quality and survival outcomes remains unknown. Overall, our findings suggest the importance of continuous process of care evaluation of organizational structures augmented by immediate after-event clinical debriefings and in-situ simulations, and the potential for this methodology to ensure best practices, as challenges evolve.

      Funding

      The study was funded by the Central Denmark Region , The Augustinus Foundation , and Holger & Ruth Hesses Mindefond . The sponsors had no role in designing or executing the study or in the interpretation, writing, or submission of the manuscript.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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