Resuscitation 41 (1999) 169–173

Appointment of a Resuscitation Training Officer is associated withimproved survival from in-hospital ventricular

fibrillation/ventricular tachycardia cardiac arrest

John McGowan a,*, Colin A. Graham b, Malcolm W.G. Gordon c

a Resuscitation Officer, Southern General Hospital, Glasgow G51 4TF, UKb Specialist Registrar in Accident & Emergency Medicine, Southern General Hospital, Glasgow G51 4TF, UK

c Consultant in Accident & Emergency Medicine, Southern General Hospital, Glasgow G51 4TF, UK

Received 14 March 1998; received in revised form 18 March 1999; accepted 15 April 1999

Abstract

Objecti6e : To determine if the appointment of a Resuscitation Training Officer improves survival to discharge from in-hospitalventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. Design : A 22-month prospective study. Setting : A 1100-bedteaching hospital. Subjects : All inpatients suffering ventricular fibrillation or ventricular tachycardia cardiorespiratory arrests.Inter6entions : Appointment of a Resuscitation Training Officer at start of study, who introduced coordinated resuscitationtraining for all staff. Main outcome : Survival to discharge. Result : Improvement in survival to discharge of 20–75% (PB0.03,Spearman Rank Correlation test). Conclusion : Appointment of a Resuscitation Training Officer is associated with improvedsurvival to discharge in ventricular fibrillation and ventricular tachycardia in-hospital cardiac arrest. © 1999 Elsevier ScienceIreland Ltd. All rights reserved.

Keywords: Training; Outcome; Cardiac arrest; Education; Basic life support

www.elsevier.com/locate/resuscitation

1. Introduction

Cardiopulmonary resuscitation techniques havebeen used for many years in attempts to revivevictims of sudden cardiac death, drowning, over-dose, etc. [1,2]. Health professionals have repeat-edly been shown to be poor performers ofcardiopulmonary resuscitation in many studies [3–6], with no grades of staff or specialties excepted.

The report of the Royal College of Physiciansprompted many hospitals and health authorities toappoint Resuscitation Training Officers [7,8].These individuals usually come from the ranks ofsenior nursing staff in accident and emergency,coronary or intensive care, or senior ambulancestaff. They all have wide experience and expertknowledge of basic and advanced life support, and

experience of teaching. Many are ResuscitationCouncil (UK) Advanced Life Support Instructors.

They are tasked with training medical, nursing,paramedical and ancillary staff to an appropriatelevel of cardiopulmonary resuscitation skill in agiven hospital or unit. Many Resuscitation Train-ing Officers also attend cardiac arrest calls in theirhospitals. Generally, they also have responsibilityfor standardisation and availability of resuscita-tion equipment in their hospitals.

It is well known that cardiopulmonary resuscita-tion training works: post-training ability has beenshown to be much better than pre-training ability[9,10]. This training is now being offered in a largenumber of hospitals by Resuscitation TrainingOfficers. However, there is little evidence [11] todate to support the impression that survival todischarge from in-hospital cardiac arrest has im-proved as a result of the appointment and subse-* Corresponding author. Tel./fax: +44-141-201-1841.

0300-9572/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved.PII: S 0 3 0 0 -9572 (99 )00046 -5

J.M

cGow

anet

al./R

esuscitation41

(1999)169

–173

170

Fig. 1. In-hospital cardiac arrest study form.

J. McGowan et al. / Resuscitation 41 (1999) 169–173 171

quent activities of a Resuscitation TrainingOfficer.

We undertook this 22-month prospective studyto determine if survival to discharge from in-hos-pital cardiac arrest due to ventricular fibrillation(VF) or ventricular tachycardia (VT) improvedfollowing the appointment of a ResuscitationTraining Officer.

2. Methods

An in-hospital cardiac arrest was defined as acardiorespiratory arrest occurring in a current hos-pital inpatient. This included patients who sus-tained a cardiac arrest while in the accident andemergency department, but excluded thosebrought into the accident and emergency depart-ment already in cardiac arrest. Patients for whomcardiac arrest calls were made, but who had notsuffered a cardiorespiratory arrest, were alsoexcluded.

Patients whose initial cardiac arrest rhythm wasasystole or electro-mechanical dissociation werenot included in this study, as the proportion ofthese patients surviving to hospital discharge is so

low that it would be difficult to demonstrate anystatistically significant change in their outcome inthe timescale of this study.

A study form (Fig. 1) was completed for eachin-hospital cardiac arrest at the end of the resusci-tation attempt. It was completed by a member ofthe resuscitation team and submitted for process-ing. If a patient had multiple in-hospital cardiacarrests during one in-patient stay, only the firststudy form was entered into the study. The studyran from 1 February 1993 to 31 October 1994inclusive. The Resuscitation Training Officer tookup his appointment on 1 February 1993. The datawere assimilated and significance was assessed us-ing the Spearman Rank Correlation test.

3. Results

Fig. 2 shows the change in survival from VF/VTcardiac arrests during the study period. An in-crease in survival has been observed over the studyperiod (coefficient 0.665, P=0.026 by SpearmanRank Correlation test). A time interval of twocalendar months was chosen for convenience andfor ease of statistical analysis.

Fig. 2. Percentage change in survival from VF/VT cardiac arrests (Spearman Rank Correlation Coefficient=0.665, P=0.026).

J. McGowan et al. / Resuscitation 41 (1999) 169–173172

4. Discussion

This observational study has demonstrated anincrease in survival in VF/VT in-hospital cardiacarrests over the study period (PB0.03)

There are many factors which could contributeto these results. The European ResuscitationCouncil published new guidelines in November1992 [12] in Brighton, simplifying the advancedlife-support management of sudden cardiac arrest.These are guidelines which were taught to medicaland nursing staff in this hospital over the studyperiod. These simpler and potentially more effec-tive guidelines may well have led to improved,prompter resuscitation attempts, thus increasingsurvival. The guidelines were not simply advertisedor made available, but staff were also trained intheir correct usage.

Another factor which may have changed is theresponse times for the resuscitation team to reachthe location of the arrest. However, there was nochange in the call system, the layout of the wardsor the method of reaching an arrest (running!)during the study period, and therefore this isunlikely to have altered survival figuressignificantly.

Over the study period, there was no expansionof the extended role of the nurse to the generalwards. Nursing staff in the medical intensive careunit (effectively equivalent to a coronary care unit)were already trained and authorised to defibrillateif appropriate, unsupervised, but this role has not,as yet, been expanded onto the general wards.Thus, more prompt defibrillation (i.e. by on-sitenursing staff) cannot explain the improved sur-vival from in-hospital VF/VT cardiac arrest.

The use of lignocaine as an antiarrhythmicagent in VF/VT cardiac arrests was generally dis-couraged in this hospital over the course of thisstudy because data [13,14] were emerging that itwas not beneficial, and potentially harmful duringa cardiac arrest. All dosages of lignocaine notedon the study forms could be considered therapeu-tic, but it is possible that as the use of intravenouslignocaine decreased, improved survival was seenas a result. This factor could partly explain thelarge increase in survival from in-hospital VF/VTcardiac arrest, although the evidence for abandon-ing the use of lignocaine is far from complete.

Another potentially confounding factor is theincreased awareness of and need for ‘do not resus-

citate’ orders. These are used when cardiopul-monary resuscitation is considered inappropriate,e.g. the patient has a terminal malignancy, termi-nal congestive heart failure, futile prognosis, etc.[15]. It is possible that the use of do not resuscitateorders has increased and therefore the survivalfigures improve because more patients with a lowprobability of surviving an in-hospital cardiac ar-rest have been taken out of the equation.

However, the total number of cardiac arrestcalls has remained fairly static throughout thestudy period and, therefore, do not resuscitateorders are unlikely to have significantly altered thesurvival figures.

The survival figures could have been changeddue to increased reporting of cardiac arrests. Thetotal number of arrests and deaths over the studyperiod remained essentially unchanged, and there-fore better reporting is only likely to be a minorcontributor to the improved figures.

Patients in the medical intensive care unit whosustained a VF/VT cardiac arrest could be defibril-lated unsupervised and quickly by nursing staff.This should theoretically improve survival, al-though it could be argued that the fact that thepatient is in the medical intensive care unit meansthat the patient is more unwell and therefore morelikely to die following a cardiac arrest. However,although the proportion of patients having a car-diac arrest in the medical intensive care unit ineach period of study remained relatively un-changed, the numbers having VF/VT arrests didvary. These variations showed no statistical differ-ence, possibly because the numbers were small.

During the study period, there were no changesto the thrombolysis policy which could be respon-sible for increased survival.

Another variable was the cardiopulmonary re-suscitation expertise of the resuscitation team andthe nursing staff. With the appointment of theResuscitation Training Officer, basic life-supporttraining was gradually provided to the majority oftrained nursing staff on the general wards. The useof basic life support improves survival from out-of-hospital VF/VT arrests [16], so improved basiclife-support techniques may have contributed tothe noted increase in survival.

The nursing staff in the intensive care, accidentand emergency, theatres and medical units weretargeted, initially, for basic life-support training

J. McGowan et al. / Resuscitation 41 (1999) 169–173 173

and simulated cardiac arrests. A cascade system ofbasic life support was introduced around the mid-point of the study (period 6) and continued there-after. Each new intake of junior medical staff (every6 months) was trained, formally, in basic andadvanced life support by the Resuscitation TrainingOfficer, in a small-group, 2.5-h training session, andsubjected to refresher sessions over the time of thestudy.

Thus, with the appointment of a ResuscitationTraining Officer, both nursing and medical staffwere receiving formal, extensive basic and advancedlife-support training, where it was lacking to a largeextent before. This would appear to be associatedwith increased survival to discharge of patientssuffering an in-hospital VF/VT cardiac arrest.

Despite the improvement in survival followingthe appointment of the Resuscitation TrainingOfficer, it is impossible to demonstrate that thisalone caused improvement; however, the lack ofchange in other confounding factors would lendsupport to the hypothesis that appointment of aResuscitation Training Officer and the changesbrought about by this improve survival from in-hos-pital VF/VT cardiac arrest.

To our knowledge, this is the first time thatincreased survival to discharge for patients sustain-ing an in-hospital VF/VT cardiac arrest has beenassociated with the appointment of a full-timeResuscitation Training Officer. This evidence raisesserious doubts about previous statements and anx-ieties on cardiopulmonary resuscitation training[17], and lends weight to the argument for appoint-ing Resuscitation Training Officers to our hospitals.

All grades and personnel in the hospital settingshould be trained [18] and there should be access tothe Resuscitation Training Officer and trainingroom for all. It is now time to acknowledge thebenefits of the appointment of a ResuscitationTraining Officer.

Acknowledgements

We thank all staff who completed study forms.We thank Dr Jan Love, Robertson Centre forBiostatistics, University of Glasgow, for invaluablestatistical advice. John McGowan is the Resuscita-tion Officer who organised the training referred toin this paper. Malcolm Gordon is the Chairman ofthe Hospital Resuscitation Committee.

References

[1] The Bible, 1 Kings:17–22.[2] Tossach WA. A man dead in appearance recovered by

distending the lungs with air. Medical Essays and Obser-vations. London.

[3] Wynne G, Martineau TM, Johnston M, Whitely CA,Evans TR. Inability of trained nurses to perform basiclife support. Br Med J 1987;294:1198–9.

[4] David J, Prior-Willeard PFS. Resuscitation skills ofMRCP candidates. Br Med J 1993;306:1578–9.

[5] Morris F, Tordoff SG, Wallis D, Skinner DV. Car-diopulmonary resuscitation skills of preregistrationhouse officers: five years on. Br Med J 1991;302:626–7.

[6] Thwaites BC, Shankar S, Niblett D, Saunders J. Canconsultants resuscitate? J R Coll Phys London1992;26:265–7.

[7] Royal College of Physicians. Resuscitation from cardiacarrest. Training and organisation. A report. J R CollPhys London 1987;21(3):175–82.

[8] Graham CA, Guest KA, Scollon D. Cardiopulmonaryresuscitation. Paper 2: a survey of basic life supporttraining for medical students. J Accident Emerg Med1994;11:165–7.

[9] Kaye W, Wynne G, Martineau T, Dubin HG, Rallis SF,Simons RS, Evans TR. An advanced resuscitation coursefor preregistration house officers. J R Coll Phys London1990;24(1):51–4.

[10] Seidelin PH, Bridges AB. Cardiopulmonary resuscita-tion: effect of training junior house officers on outcomeof cardiac arrest. J R Coll Phys London 1993;27(1):52–3.

[11] Sanders AB, Berg RA, Burress M, Genova RT, KernKB, Ewy GA. The efficacy of an ACLS training pro-gramme for resuscitation from cardiac arrest in a ruralcommunity. Ann Emerg Med 1994;23(1):56–9.

[12] Advanced Life Support Working Party of the EuropeanResuscitation Council. Guidelines for advanced life sup-port. Resuscitation 1992;24:111–22.

[13] McGowan J, Gordon MWG, Griggs N. A comparison:lignocaine versus defibrillation as first treatment, on sur-vival from cardiac arrest. J Accident Emerg Med1995;12(1):81 (Abstract).

[14] Von Planta M, Chamberlain DA. Drugs treatments ofarrhythmias during cardiopulmonary resuscitation. Re-suscitation 1992;24:227–32.

[15] Baskett PJF. The ethics of resuscitation. In: ColquhounMC, Handley AJ, Evans TR, editors. ABC of Resuscita-tion, 3rd ed. London: BMJ Publishing Group, 1995:69–73.

[16] Eisenberg MS, Horwood BT, Cummins RO, Reynolds-Hartle R, Hearne TR. Cardiac arrest and resuscitation: atale of 29 cities. Ann Emerg Med 1990;19(2):179–86.

[17] Dent THS, Gillard JH. Cardiopulmonary resuscitation:effectiveness training and survival. J R Coll Phys Lon-don 1993;27(4):354–5.

[18] Wynne G. Training and retention of skills. In:Colquhoun MC, Handley AJ, Evans TR, editors. ABCof Resuscitation, 3rd ed. London: BMJ PublishingGroup, 1995:60–2.